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The model identifies three controlling variables: treatment substitutability (TS), practice privilege constraints (PPC), and relative payment rates (RR). In the model, TS and PPC are conceptualized as determining the estimated substitutable share of costs (SSC%); RR, in combination with the values derived for SSC%, is then used to estimate potential cost savings (CS%). Two conditions were defined for each of the three controlling variables in order to provide a range of possible values for SSC% and CS%. For reasons of data availability, data were obtained from the Manitoba Health Services Commission for private practice psychiatry services for FY 1984 and estimates of SSC% calculated. These estimates were then applied to B.C. Medical Services Commission data for FY 1984, and projected values of CS% calculated. Calculations were made both for all services and for the subset of psychotherapy services, which accounted for 80 percent of the larger set of services. The results of the study indicated considerable possibilities for manpower substitution, ranging from 35 to 70 percent for all services and 40 to 75 percent for psychotherapy services. However, the study also found that while salaried psychologists offered the possibility of substantial cost savings, a \r\nfee-for-service arrangement suggested virtually no potential savings. Projected values of CS% for the salaried alternative were 20 to 40 percent for all services and 15 to 30 percent for psychotherapy services but in the fee-for-service alternative, only 4 to 8 percent for all services and 4 to 7 percent for psychotherapy services. Licensure and market rigidities which might pose barriers to implementation were evaluated and a review of professional training standards (TS), licensure standards (PPC), and funding alternatives (RR) indicated that the projected economies could be achieved with no necessity for modifications in existing arrangements. PPC appear to present almost no barriers to economies from the proposed manpower substitution and those barriers which are presented by TS and RR limitations still allow considerable potential for economies. Thus, the greatest opportunities for intervention in achieving and enhancing the projected, economies appear to be in the exploration of relative payment rates and relative effectiveness of treatment methods (e.g., psychotherapy vs. pharmacotherapy). The study concludes with a discussion of factors lying outside the boundaries of the model but which impinge, nonetheless, upon the feasibility of the proposed substitution and fall, necessarily, to policy makers to address. The existing network of B.C. community mental health centres was suggested as a possible mechanism for the delivery of the substitutable share of private practice psychiatry services.","@language":"en"}],"DigitalResourceOriginalRecord":[{"@value":"https:\/\/circle.library.ubc.ca\/rest\/handle\/2429\/27988?expand=metadata","@language":"en"}],"FullText":[{"@value":"MANPOWER SUBSTITUTION IN MENTAL HEALTH SERVICE DELIVERY By ELINOR CAROL MACPHERSON B.A., Stanford University, 1964 M.A., University of I l l i n o i s , 1969 Ph.D., University of I l l i n o i s , 1971 A THESIS SUBMITTED IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE DEGREE OF MASTER OF SCIENCE in THE FACULTY OF GRADUATE STUDIES Department of Health Care and Epidemiology Health Services Planning and Administration Program We accept this thesis as conforming to the required standard THE UNIVERSITY OF BRITISH COLUMBIA May 1988 \u00a9Copyright: Elinor Carol Macpherson, 1988 In presenting t h i s thesis i n p a r t i a l f u l f i l m e n t of the requirements f o r an advanced degree at the University of B r i t i s h Columbia, I agree that the Library s h a l l make i t f r e e l y a v a i l a b l e f o r reference and study. I further agree that permission for extensive copying of t h i s t h e s i s for s c h o l a r l y purposes may be granted by the head of my department or by h i s or her representatives. I t i s understood that copying or publ i c a t i o n of t h i s thesis for f i n a n c i a l gain s h a l l not be allowed without my written permission. Department of Health Care and Epidemiology The U n i v e r s i t y of B r i t i s h Columbia 2075 Wesbrook Place Vancouver, Canada V6T 1W5 Date A p r i l 22, 1988 i i ABSTRACT The study developed a model for projecting potential economies from manpower s u b s t i t u t i o n among the four core mental health professions and applied the model to a proposed substitution s i t u a t i o n which would substitute psychologists for psychiatrists i n the delivery of a proportion of present private practice (fee-for-service) psychiatry services i n B r i t i s h Columbia. The model i d e n t i f i e s three co n t r o l l i n g variables: treatment s u b s t i t u t a b i l i t y (TS), practice p r i v i l e g e constraints (PPC), and r e l a t i v e payment rates (RR). In the model, TS and PPC are conceptualized as determining the estimated substitutable share of costs (SSC%); RR, i n combination with the values derived for SSC%, i s then used to estimate potential cost savings (CS%). Two conditions were defined for each of the three co n t r o l l i n g variables i n order to provide a range of possible values for SSC% and CS%. For reasons of data a v a i l a b i l i t y , data were obtained from the Manitoba Health Services Commission for private practice psychiatry services for FY 1984 and estimates of SSC% calculated. These estimates were then applied to B.C. Medical Services Commission data f o r FY 1984, and projected values of CS% calculated. C a l c u l a t i o n s were made both f o r a l l s e r v i c e s and f o r the subset of psychotherapy services, which accounted for 80 percent of the larger set of services. The results of the study indicated considerable p o s s i b i l i t i e s for manpower substitution, ranging from 35 to 70 percent for a l l services and 40 to 75 percent for psychotherapy services. However, the study also found that while s a l a r i e d psychologists offered the p o s s i b i l i t y of substantial cost savings, a f ee-f or-service arrangement suggested v i r t u a l l y no p o t e n t i a l savings. Projected values of CS% for the salaried alternative were 20 to 40 percent for a l l services and 15 to 30 percent for psychotherapy services but i n the fee-for-service alternative, only 4 to 8 percent for a l l services and 4 to 7 percent for psychotherapy services. Licensure and market r i g i d i t i e s which might pose barriers to implementation were evaluated and a review of professional t r a i n i n g standards (TS), licensure standards (PPC), and funding alternatives (RR) indicated that the projected economies could be achieved with no necessity for modifications i n existing arrangements. PPC appear to present almost no b a r r i e r s to economies from the proposed manpower substitution and those barriers which are presented by TS and RR l i m i t a t i o n s s t i l l allow considerable p o t e n t i a l f o r economies. Thus, the g r e a t e s t o p p o r t u n i t i e s f o r intervention i n achieving and enhancing the projected, economies appear to be i n the exploration of r e l a t i v e payment rates and r e l a t i v e e f f e c t i v e n e s s of treatment methods (e.g., psychotherapy vs. pharmacotherapy). The study concludes with a discussion of factors lying outside the boundaries of the model but which impinge, nonetheless, upon the f e a s i b i l i t y of the proposed substitution and f a l l , necessarily, to policy makers to address. The existing network of B.C. community mental health centres was suggested as a possible mechanism f o r the d e l i v e r y of the substitutable share of private practice psychiatry services. i v TABLE OF CONTENTS Page ABSTRACT i i LIST OF TABLES v i i LIST OF FIGURES v i i i ACKNOWLEDGEMENT i x CHAPTER ONE: INTRODUCTION 1 1 .1 Objective 1 1 .2 Rationale 2 1.3 Concept of Manpower Substitution 6 1.4 Structure 8 CHAPTER TWO: MODEL FOR PROJECTING POTENTIAL ECONOMIES 10 FROM MENTAL HEALTH MANPOWER SUBSTITUTION CHAPTER THREE: THE EFFECTIVENESS OF PSYCHOTHERAPY 24 CHAPTER FOUR: THE PROFESSIONAL TRAINING STANDARDS 35 4.1 Accreditation & Training Program Standards 35 4.2 Professional Training Programs Compared 56 CHAPTER FIVE: THE PROFESSIONAL LICENSURE STANDARDS 61 5.1 Professional Licensure Standards 61 5.2 Professional Practice Privileges 67 5.3 Licensure Standards & Practice Privileges 73 Compared 5.4 Potential Practice Privileges for Psychologists 79 CHAPTER SIX: THE PROFESSIONS COMPARED AS PSYCHOTHERAPISTS 86 6.1 Perceived C r e d i b i l i t y 86 6.2 C l i n i c a l Attitudes 90 6.3 C l i n i c a l Effectiveness 93 6.4 Patterns of Practice 97 6.5 \u2022 Professions as Psychotherapists Compared 101 CHAPTER SEVEN: SUBSTITUTION S THE TREATMENT OF MENTAL DISORDERS 104 CHAPTER EIGHT: METHODOLOGY 135 8.1 Estimating Substitutable Share of Services 137 and Costs 8.2 Projecting Cost Implications of Manpower 152 Substitution V TABLE OP CONTENTS (cont.) Page CHAPTER NINE: RESULTS AND ANALYSIS 166 9.1 Estimated Substitutable Share of Services 166 and Costs 9.2 Projected Cost Implications of Manpower 190 Substitution CHAPTER TEN: DISCUSSION AND CONCLUSION 206 FOOTNOTES 225 BIBLIOGRAPHY 228 APPENDIX 245 Appendix A: The Professional Training Standards 246 Appendix B: The Professional Licensure Standards 279 Appendix C: Data 292 Appendix D: The Professional Payment Schedules 302 v i LIST OF TABLES TABLE I. TABLE I I . TABLE I I I . TABLE IV. TABLE V. TABLE VI. TABLE VII. TABLE VIII. TABLE IX. TABLE X. TABLE XI. TABLE XII. TABLE XIII. TABLE XIV. TABLE XV. Comparison of Training Programs i n the Four Core Mental Health Professions at B r i t i s h Columbia Universities Program Elements: Program Program Elements: Training Program U.B.C. Psychiatry Training S.F.U. C l i n i c a l Psychology Program Elements: Douglas College Psychiatric Nursing Training Program Program Elements: U.B.C. Social Work Training Program Licensure Standards for Mental Health Professions i n B r i t i s h Columbia Practice P r i v i l e g e s for Mental Health Professions i n B r i t i s h Columbia Substitution and the Treatment of Mental Disorders Four Scenarios for Estimating Sutstitutable Share and Projecting Cost Implications of Manpower Substitution Estimates of Treatment S u b s t i t u t a b i l i t y Estimates of Practice P r i v i l e g e Constraints Age\/Sex Population D i s t r i b u t i o n for Manitoba and B r i t i s h Columbia (June 1, 1984) Distrib u t i o n of Mental Disorders Diagnosed for Patients Discharged from Psychiatric and General Hospitals i n Manitoba and B r i t i s h Columbia (FY 1982) Fee Schedule Structure for Psychiatrists B i l l i n g Medical Plans i n Manitoba and B r i t i s h Columbia ( A p r i l , 1985) Payment Rates for Psychiatrists and Psychologists i n B r i t i s h Columbia (1985) Page 36 41 46 48 54 62 69& 70 105 139 142 145 154 155 156 162 TABLE XVI. Estimated Effect of Treatment S u b s t i t u t a b i l i t y on 167& Potential for Manpower Substitution (Private Practice 168 Psychiatry B i l l i n g s to MHSC: FY 1984) v i i LIST OF TABLES (cont.) TABLE XVII. Estimated Effect of Practice P r i v i l e g e Constraints on Potential for Manpower Substitution (Private Practice Psychiatry B i l l i n g s to MHSC: FY 1984) 171 TABLE XVIII. Substitutable Share of Private Practice Psychiatry 176& Services and Costs: Estimated Combined Effect of 177 Treatment S u b s t i t u t a b i l i t y (TS) and Practice P r i v i l e g e Constraints (PPC) on Potential for Manpower Substitution (Private Practice Psychiatry B i l l i n g s to MHSC: FY 1984) TABLE XIX. Private Practice Psychiatry Psychotherapy Services and Costs i n Manitoba and B r i t i s h Columbia (FY 1984) 181 TABLE XX. Substitutable Share of Private Practice Psychiatry Psychotherapy Services and Costs: Estimated Combined Effect of Treatment S u b s t i t u t a b i l i t y (TS) and Practice P r i v i l e g e Constraints (PPC) on Potential for Manpower Substitution (Private Practice Psychiatry B i l l i n g s to MHSC: FY 1984) 183& 184 TABLE XXI. Summary of Estimated Separate and Combined Effect 188& of Treatment S u b s t i t u t a b i l i t y (TS) and Private 189 Pri v i l e g e Constraints (PPC) on Potential for Manpower Substitution (Private Practice Psychiatry B i l l i n g s to MHSC: FY 1984) TABLE XXII. Cost Implications of Manpower Substitution for Private Practice Psychiatry Services: Projected Combined Effect of Treatment S u b s t i t u t a b i l i t y , Practice P r i v i l e g e Constraints, and Relative Payment Rate on Potential Economies (Private Practice Psychiatry B i l l i n g s to BCMSC: FY 1984) 1 94& 195 TABLE XXIII. Cost Implications of Manpower Substitution for Private Practice Psychiatry Psychotherapy Services: Projected Combined Effect of Treatment S u b s t i t u t a b i l i t y , Practice P r i v i l e g e Constraints, and Relative Payment Rate on Potential Economies (Private Practice Psychiatry B i l l i n g s to BCMSC: FY 1984) 199& 200 TABLE XXIV. Relative Payment Rates for the Four Core Mental Health Professions i n B r i t i s h Columbia (1987) 217 V l l l LIST OF FIGURES FIGURE 1. V e r t i c a l D i s t r i b u t i o n of Professional Manpower to Meet Mental Health Needs Page 11 FIGURE 2. Horizontal D i s t r i b u t i o n of Professional Manpower to Meet Mental Health Needs 1 2 FIGURE 3a. Model of Potential Economies from Mental Health Manpower Substitution: Estimating Substitutable Share of Costs 15 FIGURE 3b. Model of Potential Economies from Mental Health Manpower Substitution: Projecting Cost Implications of Manpower Substitution FIGURE 4. Model for Projecting Potential Economies from Mental Health Manpower Substitution: Matrix Format FIGURE 5a. Estimated Effects of Treatment S u b s t i t u t a b i l i t y (TS) and Practice P r i v i l e g e Constraints (PPC) on Substitutable Share of Costs for Mental Health Manpower Substitution FIGURE 5b. Projected Effects of Treatment S u b s t i t u t a b i l i t y (TS), Practice P r i v i l e g e Constraints (PPC) and Relative Payment Rate (RR) on Cost Implications of Mental Health Manpower Substitution 16 18& 19 174 192 i x ACKNOWLEDGEMENT I would l i k e to express my very great appreciation to my Thesis Committee Chairman, Dr. Morris Barer, Director, Division of Health Services Research and Development, University of B r i t i s h Columbia, for his supervision of t h i s research p r o j e c t . Dr. Barer has made himself available for consultation over a two year period and I have found his advice, and most p a r t i c u l a r l y his emphasis on excellence, both hel p f u l and challenging. I would also l i k e to thank the members of my Thesis Committee, Dr. Morton Beiser, Professor, Department of Psychiatry, University of B r i t i s h Columbia, and Mr. Jonathan Lomas, Associate P r o f e s s o r , Department of C l i n i c a l Epidemiology and B i o s t a t i s t i c s , McMaster University, for their encouragement and c r i t i c i s m . I have been most appreciative of the efforts Dr. Beiser and Mr. Lomas have made to share the i r expertise i n their respective f i e l d s with me. For th e i r f i n a n c i a l support of this project, I would further l i k e to extend my thanks to the National Health Research and Development Program, Health and Welfare Canada, and to my parents, Mr. and Mrs. J.H. Macpherson. As w e l l , for th e i r assistance with technical aspects of the project, I would l i k e to thank Mr. Alan Holtslag, Senior S t a t i s t i c a l Analyst, Manitoba Health Services Commission, Mr. Jim Henderson, Librarian, Woodward Bio-Medical Library, Mr. Barney Herring, Tetrad Computer Applications Ltd., Ms. Tracey Matovich, Research A s s i s t a n t , and Mr. Ron S i z t o , Computer Consultant, Department of Health Care & Epidemiology. Furthermore, for th e i r personal patience and encouragement, I would l i k e to thank Ms. Rose Matovich and Mr. Jack Cooper. F i n a l l y , I would l i k e to express my very great appreciation to Mrs. Lorraine Davidson for her exceptional c l e r i c a l s k i l l s i n designing and typing the manuscript. CHAPTER ONE INTRODUCTION 1.1 OBJECTIVE The objective of the present thesis project i s to develop a model of manpower substitution i n mental health service delivery. The thesis attempts to establish a range of feasible substitutions among the four core mental health professions: psychiatry, psychology, p s y c h i a t r i c nursing, and s o c i a l work. I t takes private practice psychiatry as i t s s t a r t i n g point and investigates the p o s s i b i l i t i e s for substitution among the four professions. The study places emphasis on a comparison of psychiatry and psychology, as the t r a i n i n g and licensure standards for these two professions are the most si m i l a r . I t concludes with an examination of the implications of the manpower substitution model for the cost of mental health service delivery i n the Canadian context, with p a r t i c u l a r reference to B r i t i s h Columbia. 2 1.2 RATIONALE As mental health services are currently delivered i n North America, there are four core mental health professions: psychiatry, psychology, psychiatric nursing, and psychiatric s o c i a l work. Over the past 30 years, changing perceptions of mental disorders and t h e i r proper treatment have blurred the roles of the mental health professions. At the s t a r t of t h i s t r a n s i t i o n period, with three-quarters of a l l care episodes occurring on an inpatient basis, professional roles were quite stereotyped: p s y c h i a t r i s t s treated patients, psychologists administered t e s t s , nurses dispensed medication, and s o c i a l workers made discharge plans (Blum & Redlich, 1980). Presently, with three quarters of a l l care episodes occurring on an outpatient basis and with a wider range of conditions considered appropriate for treatment, there appears to be a more e g a l i t a r i a n d i s t r i b u t i o n of functions, (McGuire, 1981). Trebilcock and Shaul (1983) have noted that the market for mental health services i s very l i g h t l y r e g u l a t e d ; with the exception of prescription and administration of medication, exclusive r i g h t s to p r a c t i c e are not recognized and, at most, certain professional t i t l e s are reserved by law to certain groups. Blum & Redlich, studying patterns of practice i n a range of Connecticut mental h e a l t h s e t t i n g s , found a sharing of treatment functions such as in d i v i d u a l and group psychotherapy by a l l mental health professions. Also i n the U.S., Webb (1970) examined the severity of mental health problems i n patients of p s y c h i a t r i s t s and psychologists i n private practice and found no s i g n i f i c a n t differences. S i m i l a r l y , Taube, Burns, and Kes s l e r (1984) found no s i g n i f i c a n t differences i n the rate of patient h o s p i t a l i z a t i o n for U.S. private practice p s y c h i a t r i s t s and psychologists. McGuire (1980) examined the di s t r i b u t i o n of psych i a t r i s t s and psychologists i n U.S. community mental 3 health centers and found that 85 percent of the variance i n s t a f f i n g could be attributed to interchangeable p r o f e s s i o n a l i n p u t s ; again, s e v e r i t y of diagnosis and r a t e of h o s p i t a l i z a t i o n did not d i f f e r s i g n i f i c a n t l y . The present author (Macpherson, 1983) has addressed the reasons for th i s overlap of function among mental health professions, developing the thesis that the overlap occurs for two reasons. F i r s t , because the study of human behaviour includes both psychological and physiological elements, much of the knowledge base of the four core mental health professions intertwines. Second, because neither the absolute nor the re l a t i v e effectiveness of the various alternate therapies for mental disorders has been d e f i n i t i v e l y demonstrated, no single profession has been able to lay claim to exclusive expertise nor have the several professions been able to agree on a d i s t r i b u t i o n of exclusive expertise. In common parlance, \"profession\" i s considered synonymous with certain occupations such as law and engineering. However, Johnson (1972) and Larson (1977), approaching the concept of professionalism from a so c i o l o g i c a l perspective, conclude that a profession i s not an occupation but rather a means of c o n t r o l l i n g an occupation and that therefore the key to professionalization i s to constitute and control a market f o r a p a r t i c u l a r form of expertise. Larson posits that i n establishing professional monopoly, the c r u c i a l intervening v a r i a b l e between expertise and market control i s \"cognitive exclusiveness,\" i . e . , proprietary rights to a body of knowledge. Hence, the present author has argued that as a re s u l t of t h e i r common knowledge base and t h e i r i n a b i l i t y to c l e a r l y establish the effectiveness of treatment, no single mental health profession has been able to establish s u f f i c i e n t cognitive exclusiveness to gain monopoly control over the market for mental health 4 services. Indeed, i n B r i t i s h Columbia current l e g i s l a t i o n s p e c i f i c a l l y authorizes both medical practitioners and psychologists to diagnose and treat mental disorders. Furthermore, B.C. Mental Health Branch p o l i c y , with the introduction of a new management information system, requires a l l s t a f f to provide a DSM-III (APA, 1980) designation for each c l i e n t , w i t h the p r o v i s o that non-licensed p r o f e s s i o n a l s are making a c l a s s i f i c a t i o n rather than a diagnosis (Copley, 1985). Hence, the treatment of mental disorders does not appear to f i t neatly into any single professional b a i l i w i c k ; several professions appear to have a legitimate claim to expertise and, as a consequence, to a share of the market for mental health services. The i s s u e of the effectiveness of t h i s expertise needs to be addressed further, for there i s no gain to be made from a substitution e f f o r t i f the treatment provided i s i t s e l f i n e f f e c t i v e . The question of whether one subset of treatments, psychotherapy, i s effec t i v e has been the subject of intense, even acrimonious, debate (Bergin 1971; Bergin & Lambert, 1978; Casey & Berman, 1985; Eysenck, 1952, 1965, 1966, 1978; Gallo, 1978; Ga r f i e l d , 1983; Luborsky, Singer & Luborsky, 1975; Meltzoff & Kornreich, 1970; P a r l o f f , 1978; Rachman, 1973; Smith & Glass, 1977; Smith, Glass, & M i l l e r , 1981; Wilson & Rachman, 1983). The Office of Technology Assessment (OTA, 1980), i n i t s paper \"The Efficacy and Cost E f f e c t i v e n e s s of Psychotherapy,\" provides a balanced summary of the present state of knowledge. OTA concludes that the currently available l i t e r a t u r e contains a number of good quality research studies and a number of meta-analyses of these studies which f i n d p o s i t i v e outcomes for psychotherapy. A more comprehensive discussion of the effectiveness of psychotherapy i s presented i n Chapter Three. 5 Thus although research on professional substitution i n mental health services delivery involves the caveat that we have no t r u l y adequate operational d e f i n i t i o n of quality of service, examinations of present patterns of s t a f f i n g and patterns of practice indicate that considerable substitution occurs and suggest the p o s s i b i l i t y for s t i l l further substitution. Given the range of reimbursement rates across the four core mental health professions, the implication i s that greater cost effectiveness could be achieved i n the delivery of mental health services. In B r i t i s h Columbia, a comparison of 1987 p r o v i n c i a l salary and sessional rates i l l u s t r a t e s t h i s reimbursement d i f f e r e n t i a l . Salary payments f o r p s y c h i a t r i s t s range from $66,000 to $83,000 1, f o r p s y c h o l o g i s t s from $35,000 to $48,0002, for psychiatric nurses from $27,000 to $34,0003, and for psychiatric s o c i a l workers from $26,000 to $35,000^. Sessional rates (3 1\/2 hours) for p s y c h i a t r i s t s range from $211 to $273 1, and for psychologists from $92 to $155 5. Nevertheless, although substitution may be technically feasible and desirable, the market for health services i n general and for mental health services\u2022as a subgroup appears to leave much of that f e a s i b i l i t y as no more than p o t e n t i a l . Evans (1984) reviewed a series of studies which suggest that i n Canada and the United States reductions of as much as 40 percent of t o t a l expenditures could be achieved without loss of quality on dental services, pharmaceutical dispensing, and ophthalmic goods through r a t i o n a l i z a t i o n of production and use of less expensive personnel. Lomas and Stoddart (1985) found that 40 to 90 percent of primary care p h y s i c i a n o f f i c e v i s i t s could be delegated to nurse pra c t i t i o n e r s . In a study of agencies providing services to emotionally d i s t u r b e d c h i l d r e n , Macpherson (1982) found that while p a t i e n t populations, patient\/staff r a t i o s , and treatment programs were s i m i l a r , 6 costs d i f f e r e d considerably, i n large measure as a function of s t a f f s a l a r i e s , with the yearly cost per c h i l d ranging from $4,000 i n a unit staffed by teachers, teacher aides, and c h i l d care workers to $15,000 i n a unit staffed by teachers and p s y c h o l o g i s t s . Hence, given the p o s s i b i l i t y of s u b s t i t u t i o n and the existence of a range of reimbursement rates, there may be room for more cost effective delivery of mental health services p a r a l l e l to the potential i n other areas of health service delivery. 1.3 CONCEPT OF MANPOWER SUBSTITUTION Although substitution i s the term commonly employed i n discussions of how we might economize i n service delivery by the use of less costly personnel, substitution should not be taken to imply that less costly personnel are necessarily less well trained to perform tasks considered substitutable. Perhaps a l l o c a t i o n rather than substitution would be a more apt designation for the process we are addressing. Hence, rather than considering substitution as the replacement of \"senior\" personnel with \"junior\" personnel, Lomas (1986) has suggested that we begin our enquiry with the need for mental health services and then examine how the servicing of that need might be apportioned so that tasks are assigned i n the most cost-effective manner. Thus, for example, i f a s i t u a t i o n of unmet needs were perceived, i t would be regarded as a shortage of s e r v i c e s rather than as necessarily a shortage of any p a r t i c u l a r type of professional input (McGuire, 1980). Using t h i s approach, McGuire provides an excellent analysis of s u b s t i t u t a b i l i t y i n mental health service delivery. McGuire notes that economists d i s t i n g u i s h two types of s u b s t i t u t a b i l i t y : s u b stitut- a b i l i t y i n production and s u b s t i t u t a b i l i t y i n demand. In meeting mental 7 health service needs, s u b s t i t u t a b i l i t y i n production would be said to exis t i f alternate professional inputs could be used to produce the same professional output. For example, any of the four core mental health professions may be equally s k i l l e d i n conducting intake interviews or d e l i v e r i n g psychotherapy at a mental health f a c i l i t y . Likewise, a general medical p r a c t i t i o n e r and a psychologist working together may be able to provide the same service as a ps y c h i a t r i s t working alone i n a correctional i n s t i t u t i o n . S u b s t i t u t a b i l i t y i n demand would be said to exis t i f different professional inputs produced different outputs which were nevertheless considered by consumers to meet the same need. Thus, f o r i n s t a n c e , mental h e a l t h c l i e n t s may judge psychotherapy and pharmacotherapy equally e f f e c t i v e i n r e l i e v i n g anxiety states. McGuire presents a useful elaboration of the concept of substitut-a b i l i t y i n production by distinguishing between simple substitution and complex substitution. In simple substitution, Professional I does the same thing as Professional I I . In complex substitution Combination I of workers can accomplish the same task as Combination I I of workers; that i s , many inputs are used i n combination with one another i n the production of services and substitution takes the form of changes i n the combination of inputs. The present research project focusses s p e c i f i c a l l y on the potential for s u b s t i t u t a b i l i t y i n the production of private practice psychiatry services i n the Canadian context. The study i s designed to compare the tasks of one type of mental h e a l t h worker, f e e - f o r - s e r v i c e p s y c h i a t r i s t s , with the tasks of another, psychologists. Hence, i t i s , i n p r i n c i p l e , capable of i d e n t i f y i n g p o s s i b i l i t i e s f o r s i m p l e s u b s t i t u t i o n i n the production of these services. The study then projects the potential for cost savings from such a substitution. In 8 more general terms, the present research project discusses the potential for both s u b s t i t u t a b i l i t y i n production and s u b s t i t u t a b i l i t y i n demand across a l l four core mental health professions, addresses p o s s i b i l i t i e s for both simple and complex substitution and examines the pot e n t i a l for cost savings which might res u l t from such a reallocation of service delivery. 1.4 STRUCTURE To accomplish t h i s investigation of substitution p o s s i b i l i t i e s the study develops a model for projecting potential economies from mental health manpower substitution and applies that model to what i s presently fee-for-service psychiatric practice i n B r i t i s h Columbia. The study deals with the direct costs of service provision and does not examine r e l a t i v e effectiveness or i n d i r e c t costs. In three steps, the study investigates' the following three questions: 1\u2022 Which services present the p o s s i b i l i t y for substitution? 2. What would be the projected cost implications of implementing such substitutions? 3. What licensure and market r i g i d i t i e s would need to be changed for implementation? The remainder of the t h e s i s i s organized into nine chapters. Chapter Two presents a discussion of the model of s u b s t i t u t a b i l i t y , which can be conceptualized i n matrix form and used to project cost d i f f e r e n t i a l s f o r manpower s u b s t i t u t i o n i n mental h e a l t h s e r v i c e delivery under current and hypothetical t r a i n i n g , licensure and funding arrangements. In the matrix, the f i r s t a x i s contains treatment substitution p o s s i b i l i t i e s , the second axis contains practice p r i v i l e g e p o s s i b i l i t i e s , the t h i r d axis contains r e l a t i v e payment p o s s i b i l i t i e s , 9 and the c e l l s indicate projected cost d i f f e r e n t i a l s under d i f f e r i n g p o l i c y options. Chapters Three through Seven address the f i r s t question and examine the p o s s i b i l i t i e s for simple substitution. These chapters document the relationship between, on the one hand, treatment practices, t r a i n i n g standards, licensure standards, and practice p r i v i l e g e s , and, on the other hand, substitution p o s s i b i l i t i e s . Chapters Eight and Nine attempt to provide quantitative answers to both the f i r s t and second questions, examining substitution p o s s i b i l i t i e s and cost implications under various treatment s u b s t i t u t a b i l i t y , practice p r i v i l e g e , and r e l a t i v e payment conditions. These two chapters present the methodology and the results of the study. Chapter Ten addresses the t h i r d question and presents a discussion of the p o l i c y implications of these projected substitution arrangements\u2022 10 CHAPTER TWO MODEL FOR PROJECTING POTENTIAL ECONOMIES FROM MENTAL HEALTH MANPOWER SUBSTITUTION In considering the f e a s i b i l i t y of manpower substitution i n the delivery of mental health services, I have suggested that i t may be more useful to conceptualize mental health needs as being allocated rather than substituted among the professions and that where more than one profession can e f f e c t i v e l y perform the treatment function, the delivery of that service could reasonably be allocated to the least expensive personnel. Previously, when treatment was delivered primarily on an inpatient basis, i t was probably more accurate to consider manpower d i s t r i b u t i o n as h i e r a r c h i c a l , as i l l u s t r a t e d i n Figure 1, with \"junior\" professions substituting at times for \"senior\" professions. In t h i s s i t u a t i o n , the junior profession may indeed have functioned i n a supporting r o l e and to substitute the junior p r o f e s s i o n f o r the senio r profession might have been a cheaper but second-best alternative, a trade-off of economy for competence. However, with treatment presently d e l i v e r e d primarily on an outpatient basis, the documentation on professional t r a i n i n g standards and professional licensure standards and the l i t e r a t u r e on the r e l a t i v e effectiveness of the d i s c i p l i n e s as psychotherapists suggest the p o s s i b i l i t y of considerable f l e x i b i l i t y i n manpower a l l o c a t i o n without a corresponding s a c r i f i c e i n quality. Perhaps a horizontal conceptualization of manpower d i s t r i b u t i o n , as suggested by Lomas (1986) and i l l u s t r a t e d i n Figure 2, might be a more helpful t o o l i n considering the a l l o c a t i o n of treatment functions among d i s c i p l i n e s . In the horizontal configuration, the professions have some s k i l l s i n common and some s k i l l s which are unique. In the present context, we are addressing that area of convergence of s k i l l s which might permit more than one profession to deliver some of the services 11 FIGURE 1 VERTICAL DISTRIBUTION OF PROFESSIONAL MANPOWER TO MEET MENTAL HEALTH NEEDS PROFESSION JROFESSION x XXX x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x . x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x PROFESSION ASSESSMENT TREATMENT FOLLOWUP 12 FIGURE 2 HORIZONTAL DISTRIBUTION OF PROFESSIONAL MANPOWER TO MEET MENTAL HEALTH NEEDS MENTAL HEALTH NEEDS MENTAL HEALTH PROFESSIONS RELATIONSHIP 13 presently provided by private practice psychiatry and the possible economies which might be achieved. The model used for projecting potential economies from mental health manpower substitution i n t h i s thesis, i s based on the premise that three c o n t r o l l i n g v a r i a b l e s determine the cost i m p l i c a t i o n s of manpower s u b s t i t u t i o n : treatment s u b s t i t u t a b i l i t y (TS), p r a c t i c e p r i v i l e g e c o n s t r a i n t s (PPC), and r e l a t i v e payment r a t e (RR). Treatment s u b s t i t u t a b i l i t y refers to the degree to which the professional t r a i n i n g standards f o r the four core mental health professions create areas of overlapping s k i l l s i n the treatment of mental disorders. Practice p r i v i l e g e constraints refers to the degree to which the extant professional licensure standards and informal practice p r i v i l e g e s for the four professions create areas of overlapping service delivery. Relative payment rate refers to the degree to which the funding arrangements for the professional groups create possible savings i n personnel costs. The model proceeds i n two stages. In the f i r s t stage, the model permits the estimation of the potential for manpower substitution, that i s , the substitutable share of present services and costs. In the second stage, costs or prices are applied to the results of the f i r s t stage, to project the potential cost d i f f e r e n t i a l s from such a manpower substitution. Figures 3a and 3b present the model i n graphic form. In Figure 3a, TS and PPC have been designated as the horizontal and v e r t i c a l axes, Axis I and Axis I I respectively, of the diagram. The separate effects of TS and PPC have been conceptualized as each contributing to the p o s s i b i l i t i e s f o r manpower s u b s t i t u t i o n . Hence, the greatest p o t e n t i a l f o r manpower substitution i s hypothesized to occur i n the lower right-hand corner of Figure 3a, at that point i n the convergence of the values of TS and PPC where the majority of treatment expenditures are for treatments with the greatest 14 overlapping of professional s k i l l s (highest treatment s u b s t i t u t a b i l i t y ) and f o r s e r v i c e s with the greatest overlapping of service delivery (lowest practice p r i v i l e g e constraints). In Figure 3b, TS, PPC, and RR have been diagrammed as the three axes of a cube, as Axis I, Axis I I , and Axis I I I respectively, and th e i r separate effects have been conceptualized as each c o n t r i b u t i n g to the p o s s i b i l i t i e s for economies from such substitution. Hence, as i l l u s t r a t e d i n Figure 3b, the greatest potential for economies i s hypothesized to occur i n the lower f r o n t right-hand corner, when the conditions of overlapping professional s k i l l s , overlapping service delivery, and savings i n personnel costs converge at t h e i r maximum values. The f i r s t stage of the model and the second stage of the model stand i n the following relationship to each other. In the f i r s t stage, although the values of both TS and PPC may suggest considerable potential for manpower substitution, economies from substitution w i l l arise i n the second stage only i f the values of RR also offer the p o s s i b i l i t y of s i g n i f i c a n t savings i n personnel costs. Likewise, while i n the second stage the values of RR may suggest the p o s s i b i l i t y of considerable economies from substitution, i f i n the f i r s t stage the values of either TS or PPC severely l i m i t the scope of such substitution, then, again, the pot e n t i a l for economies from manpower substitution w i l l be severely l i m i t e d as we l l . Figure 4 presents i n matrix format a further elaboration of the model to permit q u a n t i f i c a t i o n of the effects of TS, PPC, and RR for a s p e c i f i c manpower substitution s i t u a t i o n . The matrix format proceeds i n two stages, p a r a l l e l to the graphic format of Figures 3a and 3b. In the f i r s t stage, as i n Figure 3a, Axis I and Axis I I represent the co n t r o l l i n g variables TS and PPC. When the conditions defined to TS and PPC are quantified on the appropriate axes as values of TS% and PPC%, the model formulae permit the calculation of the effects of TS and PPC on manpower substitution IS FIGURE 3a MODEL OF POTENTIAL ECONOMIES FROM MENTAL HEALTH MANPOWER SUBSTITUTION: ESTIMATING SUBSTITUTABLE SHARE OF COSTS AXIS I 7. OF COSTS FOR SUBSTITUTABLE TREATMENTS \u00ab a co W H H t-l M < Z \u00ab 05 H W 01 o w u CO w o w X W w < CO PS o tn CO H CO o CJ Pu o > \u00ab Ui o H o < OS 100 16 FIGURE 3b MODEL OF POTENTIAL ECONOMIES FROM MENTAL HEALTH MANPOWER SUBSTITUTION: PROJECTING COST IMPLICATIONS OF MANPOWER SUBSTITUTION 17 p o s s i b i l i t i e s . The separate e f f e c t s of TS and PPC on the p o t e n t i a l formanpower substitution can be calculated using the model Formulae A - D and Formulae E - H respectively. The model Formulae I - L permit the calculation of the combined e f f e c t of TS and PPC on the p o t e n t i a l f o r manpower substitution, or, i n other words, the substitutable share of services and costs. The values of the substitutable share of costs (SSC$ & SSC%) are then entered i n the c e l l s of the f i r s t stage of the matrix. To i l l u s t r a t e the matrix format using the substitutable share of costs as an example, the doll a r value of the substitutable share of costs (SSC$) i s calculated by m u l t i p l y i n g the values of TS% and PPC% for each set of combined TS\/PPC conditions by the present costs, as broken down into the costs for each p o s s i b l e TS category and PPC category combination (PC$(TS&PPC)). The percentage of the substitutable share of costs (SSC%) i s then calculated by div i d i n g SSC$ by the t o t a l costs of present services (TPC$). In the second stage of the matrix model, as i n Figure 3b, Axes I, I I , and I I I again represent the c o n t r o l l i n g variables TS, PPC, and RR. In the matrix format, when the values for TS%, PPC%, and RR% are indicated on the approximate axes, the model Formulae 0 - Q permit the calculation of the combined effect of TS, PPC, and RR on the cost implications of the proposed manpower substitution. In the second stage, the combined effect of TS and PPC on the p o s s i b i l i t i e s for manpower substitution are collapsed into the s i n g l e terms SSC$ and SSC%. The projected costs of alternate service arrangements (CA$) are calculated by multiplying the t o t a l costs of present service arrangements (TPC$) by the percentage of the substitutable share of costs (SSC%) and the r e l a t i v e payment rate (RR%). The projected d o l l a r value of cost savings (CS$) can then be calculated by subtracting CA$ from SSC$. The percentage of cost savings (CS%) i s calculated by dividing CS$ by TPC$. These values for CA$, CS$, and CS% are then entered i n the c e l l s of the 18 FIGURE 4 MODEL FOR PROJECTING POTENTIAL ECONOMIES FROM MENTAL HEALTH MANPOWER SUBSTITUTION: MATRIX FORMAT ESQMKEIM5 SUBSCTTUTABLE SHARE OF COSTS PntfnHfll for MFmpnwpr Substitution (Etarnnlae A \u2014 M) PRESENT SERVICE ARRANGEMENTS Present Costs TPC$ PC$(TS&PPC) AXIS II (PPC) Practice Privilege Constraints PPC% AXIS I (TS) Treatment Substitutability TS% SSC$ = PC$(TSSPPC) x TS% x PPC% ssc% = ssc$\/rpc$ PRaiM:riNG COST iMPT.TcarrroNS OF MANPOWER stBsnmncN BahpnHal Ccet Differentials (Etarnnlae N \u2014 S) ALTEraJATE SERVICE ARRANGEMENTS AXIS III (RR) Alternate Funding Arrangements Relative Payment Rates RR% RR% = ARS\/PRS AXIS I (TS) Treatment Substitutability TS% AXIS n (PC) Practice Privilege Constraints CA$ = TPC$ x SSC% x RR% PPC% CS$ = SSC$ - CA$ CS% = CS$\/TPC$ 19 FIGURE 4 (Continued) TPC$ = Total present costs ($) PC$(TS&PPC) = Present costs by TS and PPC category combinations ($) SSC$ = Substitutable share of costs ($) SSC% = Substitutable share of costs (%) PR$ = Present payment rate ($) AR$ = Alternate payment rate ($) CA$ = Total costs of alternate services ($) CS$ = Cost savings ($) CS% = Cost savings (%) TS% = Treatment substitutability (%) PPC% = Practice privilege constraints (%) RR% = Relative payment rate (%) 20 second stage of the matrix for the various conditions defined for TS, PPC, and RR. I t may be of interest to note that per capita costs can also be calculated (Formulae M and R) both for stage one (PCap$) and for stage two (CapA$) of the model and entered i n the c e l l s of the matrix as we l l . These values of per capita cost can then be compared across the two stages of the model and also with the t o t a l per capita costs (TCap$). The model formulae and the def i n i t i o n s of formulae terms are summarized below: I. MODEL FORMULAE: Formulae in bold type are indicated in Figure 4. CONTROLLING VARIABLES (Axis I) TS = Treatment s u b s t i t u t a b i l i t y (Axis II) PPC = Practice p r i v i l e g e constraints (Axis I I I ) RR = Relative payment rate ESTIMATING SUBSTITUTABLE SHARE OF SERVICES AND COSTS Estimating Effect of TS on Potential for Manpower Substitution: (Formula A) ETSS# = PS#(TS) x TS% (Formula B) ETSS% = ETSS#\/TPS# (Formula C) ETSC$ = PC$(TS) x TS% (Formula D) ETSC% = ETSC$\/TPC$ Estimating Effect of PPC on Potential for Manpower Substitution: (Formula E) EPPCS# = PS#(PPC) x PPC% (Formula F) EPPCS% = EPPCS#\/TPS# (Formula G) EPPCC$ = PC$(PPC) x PPC% (Formula H) EPPCC% = EPPCC$\/TPC$ Estimating Substitutable Share of Services and Costs: (Formula I) SSS# = PS#(TS&PPC) x TS% x PPC% (Formula J) SSS% = SSS#\/TPS# (Formula K) SSC$ = PC$(TS&PPC) x TS% x PPC% (Formula L) SSC% = SSC$\/TPC$ (Formula M) PCap$ = SSC$\/Pop# PROJECTING COST IMPLICATIONS OF MANPOWER SUBSTITUTION Estimating Relative Payment Rate: (Formula N) RR% = AR$\/PR$ 21 II. Projecting Costs and Cost Savings of Alternate Service Arrangements; (Formula 0) CA$ = TPC$ x SSC% x RR% (Formula P) CS$ = SSC$ - CA$ (Formula Q) CS% = CS$\/TPC$ (Formula R) CapA$ = CA$\/Pop# Estimating Substitutable Share of Costs for Second Data Set: (Formula S) SSC$X = TPC$X x SSC% DEFINITION OF TERMS TERMS WITH VALUES DERIVED FROM EXISTING DATA Controlling Variables: TS% = Treatment s u b s t i t u t a b i l i t y (percent) PPC% = Practice p r i v i l e g e constraints (percent) RR% = Relative payment rate (percent) PR$ = Present payment rate (dollars) AR$ = Alternate payment rate (dollars) Population: Pop# = Population (number) Present Services and Costs: TPS# PS#(TS) PS#(PPC) PS#(TS&PPC) TPC$ PC$(TS) PC$(PPC) PC$(TS&PPC) TCap$ TPC$X = Total present services (number) = Present services by TS categories (number) = Present services by PPC categories (number) = Present services by TS and PPC category combination (number) = Total present costs (dollars) = Present costs by TS categories (dollars) = Present costs by PPC categories (dollars) = Present costs by TS and PPC category combinations (dollars) = Total per capita costs (dollars) = Total present costs for second data set (dollars) TERMS WITH VALUES DERIVED FROM MODEL FORMULAE Estimating Effect of TS on Potential for Manpower Substitution: ETSS# = Effect of TS for services (number) ETSS% = Effect of TS for services (percent) ETSC$ = Effect of TS for costs (dollars) ETSC% = Effect of TS for costs (percent) Estimating Effect of PPC on Potential for Manpower Substitution 22 EPPCS# = Effect of PPC for services (number) EPPCS% = Effect of PPC for services (percent) EPPCC$ = Effect of PPC for costs (dollars) EPPCC% = Effect of PPC for costs (percent) Estimating Substitutable Share of Services and Costs; SSS# = Substitutable share of services (number) SSS% = Substitutable share of services (percent) SSC$ = Substitutable share of costs (dollars) SSC% = Substitutable share of costs (percent) PCap$ = Present per capita costs of substitutable share of costs (dollars) Estimating Relative Payment Rate; RR% = Relative payment rate (percent) Projecting Costs and Cost Savings of Alternate Service Arrangements: CA$ = Total costs of alternate services (dollars) CS$ = Cost savings (dollars) CS% = Cost savings (percent) CapA$ = Per capita costs of alternate services (dollars) Estimating Substitutable Share of Costs for Second Data Set: SSC$X = Substitutable share of costs for second data set (dollars) To summarize, the above model for projecting potential economies from mental health manpower substitution i s applied i n the present study to a p o t e n t i a l manpower s u b s t i t u t i o n s i t u a t i o n which would s u b s t i t u t e psychologists i n the delivery of some of the services presently provided by private practice p s y c h i a t r i s t s . Thus, i n t h i s case, the model i s u t i l i z e d to p r o j e c t the p o t e n t i a l cost savings from s u b s t i t u t i n g an a l t e r n a t e professional group for the present professional group i n the delivery of a set of mental health services whose boundaries are defined by a funding arrangement. As w e l l , the model i s applied, with appropriate modifications, to project the cost savings for the subset of psychotherapy s e r v i c e s . Although the model i s u t i l i z e d i n the present study to project cost savings, i t might equally w e l l be used to project cost increases. Further, although only two conditions were defined for each of the c o n t r o l l i n g variables, the model does not l i m i t the possible values which might be assigned to TS%, PPC% and RR%. Likewise, although comparisons are made across two professional groups, comparisons might also be carried out across several professional groups, or, a l t e r n a t i v e l y , within a single professional group. F i n a l l y , the boundaries of the set of services encompassed by the proposed substitution can be defined by any of a number of di f f e r e n t c r i t e r i a ; i n t h i s case, the boundaries are delimited by the funding arrangement for the larger set of services and by type of treatment for the subset of psychotherapy services. However, other examples of boundary c r i t e r i a might include p a r t i c u l a r licensure arrangements or p a r t i c u l a r c l a s s i f i c a t i o n s of mental disorders. 24 CHAPTER THREE THE EFFECTIVENESS OF PSYCHOTHERAPY Psychotherapy services constitute the majority of the services delivered by private practice psychiatrists i n the two j u r i s d i c t i o n s examined i n the p r e s e n t s t u d y . The data on f e e - f o r - s e r v i c e b i l l i n g s submitted by psyc h i a t r i s t s for f i s c a l year 1984 i n Manitoba and B r i t i s h Columbia indicate that the claims for psychotherapy services constituted 80.4% and 76.0% of t o t a l claims respectively. Thus, i n order to establish the f e a s i b i l i t y of manpower s u b s t i t u t i o n f o r p r i v a t e p r a c t i c e psychiatry services, i t i s essential to document that a l l four core mental h e a l t h p r o f e s s i o n s are trained and licensed to provide psychotherapy services and that the four professions do not d i f f e r i n t h e i r e f f e c t i v e n e s s as p s y c h o t h e r a p i s t s . However, i n order to make statements about possible cost savings through manpower substitution i n mental health service delivery, we must f i r s t be able to make statements about the effectiveness of that service. Drummond (1980) makes this point i n the context of medical technology and the p r i n c i p l e i s equally true for mental health technology: \"Economic appraisal r e l i e s p a r t l y on medical appraisal for the assessment of changes i n h e a l t h state. Therefore, economic a p p r a i s a l can only be as good as the medical appraisal upon which i t i s superimposed (p.45).\" S i m i l a r l y , Barer (1982) has made the point that economic evaluation hinges c r i t i c a l l y upon technical evaluation. With regard to manpower substitution for p u b l i c l y funded services, i t can be argued that i f a treatment does no good, either i t should not be given at a l l or i f society deems i t should be offered regardless, then a l l o c a t i o n of manpower on the basis of expertise i s irrelevant and the treatment should be provided by the least expensive personnel. Likewise, i f a treatment does good, then a l l o c a t i o n should be on the basis of expertise and i f expertise can be shown to be equal, the treatment should be provided by the least expensive personnel. F i n a l l y , i f two treatments do equal good, consumers could be offered a choice regardless of cost or consumers could be offered the least expensive treatment; i n either case, as i n the preceding example, al l o c a t i o n should be on the basis of expertise and i f expertise can be shown to be equal, treatment should be provided by the least expensive personnel. If some consumers decide to purchase services p r i v a t e l y , then they w i l l no doubt weigh the choices of treatment, p r i c e , and ambience offered by professionals i n private practice. The two p r i n c i p a l treatments o f f e r e d f o r mental d i s o r d e r s are psychotherapy and pharmacotherapy, either alone or i n combination. As noted e a r l i e r , e x c l u s i v e r i g h t s to practice psychotherapy are not recognized; however, the right to practice pharmacotherapy has been reserved to the medical profession. In considering the f e a s i b i l i t y of manpower substitution for services presently delivered i n private practice psychiatry, we need to address the circumstance that p s y c h i a t r i s t s are permitted to practice both psychotherapy and pharmacotherapy, psychologists and s o c i a l workers are permitted t o p r a c t i c e only psychotherapy, and p s y c h i a t r i c nurses are permitted to practice psychotherapy and the administration\/monitoring of psychotropic medications but not t h e i r prescription. Thus, i n examining the p o s s i b i l i t y of simple substitution, the onus i s on the investigator to make the case that for at least some of the mental disorders treated i n private practice psychiatry, the effectiveness of psychotherapy i s equal to or greater than the effectiveness of pharmacotherapy. This chapter reviews the outcome l i t e r a t u r e on the absolute effectiveness of psychotherapy, which indicates that psychotherapy can indeed be an effec t i v e treatment for some 26 mental disorders. Chapters Four and Five document the trai n i n g standards and licensure standards which permit a l l four core mental health professions to practice psychotherapy. Chapter Six reviews, the l i t e r a t u r e comparing the r e l a t i v e effectiveness of the four professions as psychotherapists. Chapter Seven concludes the introductory chapters with an examination of those services which have the p o s s i b i l i t y for substitution; the chapter reviews the outcome l i t e r a t u r e on the r e l a t i v e e f f e c t i v e n e s s of psychotherapy and pharmacotherapy and discusses the relationship between treatment practice and the f e a s i b i l i t y of manpower substitution. In a consideration of the effectiveness of psychotherapy, there are two elements which require r e f l e c t i o n . F i r s t , there i s the delimitation of what i s meant by psychotherapy. A frequently c i t e d d e f i n i t i o n of psychotherapy i s that of Meltzoff and Kornreich (1970): \"Psychotherapy i s taken to mean the informed and planful a p p l i c a t i o n of t e c h n i q u e s d e r i v e d from e s t a b l i s h e d p s y c h o l o g i c a l p r i n c i p l e s , by persons q u a l i f i e d through train i n g and experience to understand these p r i n c i p l e s and to apply these techniques with the i n t e n t i o n of assi s t i n g i n d i v i d u a l s to modify such personal c h a r a c t e r i s t i c s as feelings, values, attitudes, and behaviors which are judged by the therapist to be maladaptive or maladjustive (p.6).\" Second, there i s the method of determining when effectiveness has been demonstrated. Since single studies of psychotherapy outcomes usually do not provide s u f f i c i e n t \"weight of evidence,\" such judgments are usually made through l i t e r a t u r e reviews, box-score analyses, or meta-analyses of studies reported i n the l i t e r a t u r e . The procedure of box-score analysis begins with the selection of a population of research studies. Typically, the reviewer establishes certain c r i t e r i a and excludes s t u d i e s which are not s u f f i c i e n t l y rigorous i n methodology or which are otherwise i n a p p r o p r i a t e . The reviewer then c l a s s i f i e s process v a r i a b l e s (e.g., \"yes,\" \"no,\" \" e q u i v o c a l \" ) . The d i s t i n c t i o n between the l i t e r a t u r e review and the box-score analysis i s not sharply drawn; however, i t i s the more e x p l i c i t description of selection c r i t e r i a which d i f f e r e n t i a t e s the box-score technique. S t i l l , the box-score analysis has been c r i t i c i z e d as s i m p l i s t i c and permitting, too much lat i t u d e for i n d i v i d u a l judgement. Most importantly, i t does not have the capacity to include strength of treatment effect i n i t s analysis. Meta-analysis employs s t a t i s t i c a l techniques for aggregating data and for determining relationships between causal variables and treatment outcomes (usually quantified). Studies are coded on a set of variables that are thought to be related to outcomes. These measures are l a t e r correlated with the outcomes and used as the basis for organizing outcome results i n terms of aspects of the studies. The e a r l i e s t review of psychotherapy outcome studies was Eysenck's work (Eysenck, 1952). Selecting 24 research studies, which included 8,053 cases of psychotherapy with neurotic patients, Eysenck divided the studies into two groups, p s y c h o a n a l y t i c t h e r a p y and e c l e c t i c t h e r a p y . To a s s e s s e f f e c t i v e n e s s , Eysenck developed a r a t i n g scale of improvement following therapy. In the e c l e c t i c therapy group, he calculated an improvement rate of 64 percent w i t h i n two years. In the psychoanalytic therapy group, he calculated an improvement rate of 44 percent within two years. He then compared these outcome rates against two no-treatment groups. One no-treatment group was provided by data from a study by Denker (1946); Denker's data c o n s i s t e d of insurance company records on 500 individuals who had submitted mental d i s a b i l i t y claims and been treated by general p r a c t i t i o n e r s . Denker found that w i t h i n one year, without r e c e i v i n g any s p e c i f i c psychotherapy, 44 percent had returned to work and that within two years, an a d d i t i o n a l 27 percent had returned to work. On the basis of these comparisons, Eysenck concluded that the no-treatment improvement rate was 28 approximately the same as that of the e c l e c t i c treatment groups and that the psychoanalytic improvement rate was i n f e r i o r to that of the no-treatment groups\u2022 Eysenck's review e l i c i t e d a number of important a r t i c l e s c r i t i q u i n g his work. Luborsky (1954) noted that i t was d i f f i c u l t to evaluate Eysenck's conclusions since i t was not clear what was done i n each of the studies. Meltzoff and Kornreich(1970) pointed out that Eysenck's control data for the effects of treatment were drawn from non-randomly selected control groups, whose subjects may have been more or less troubled and dysfunctional than those who sought psychotherapy. Furthermore, M e l t z o f f and Kornreich suggested that Denker's study was not a true no-treatment group i n t h a t patients were provided with sedatives, reassurance, and a placebo type of treatment. Bergin (1971) argued t h a t Eysenck had made e r r o r s i n h i s categorizing of the studies and i n the way he handled the data. Bergin reanalyzed the data used i n Eysenck's review and found a d i f f e r e n t improvement rate for the psychoanalytic treatment group. In addition, Bergin calculated a different remission rate for the no-treatment groups and judged that only about 30 percent of the patients would have recovered had there been no psychotherapy. In a general evaluation of Eysenck's report, Bergin concluded that global statements about the effectiveness of psychotherapy were meaningless and suggested that one must analyze s p e c i f i c therapies for s p e c i f i c problems. The controversy continued as Eysenck updated his o r i g i n a l research (Eysenck, 1966); he acknowledged many of the methodological problems of his e a r l i e r report and c i t e d 11 additional studies. Although Eysenck stood by his o r i g i n a l conclusion, he found supportive evidence for at least one type of psychotherapy, the behavioral approach of systematic desensitization. However, he was again c r i t i c i z e d for. s e l e c t i v e l y reviewing the l i t e r a t u r e 29 s i n c e by that time there were at l e a s t 70 control-group s t u d i e s of psychotherapy, most of which Eysenck ignored. Meltzoff and Kornreich made an important departure from e a r l i e r reviews by c l a s s i f y i n g studies of psychotherapy outcome by methodological adequacy. In t h e i r category of \"adequate\" research designs, they included studies which used a control group condition and adequate outcome measures. In t h e i r \"questionable\" category, they included studies with control groups that may not have been comparable, that used poor outcome measures, or that used inadequate analysis procedures. Their review included approximately 100 control-group studies. According to Smith, Glass, and M i l l e r (1981), who tabulated the results of Meltzoff and Kornreich's review, 80 percent of the controlled studies yielded p o s i t i v e r e s u l t s . They also found a pos i t i v e relationship between research quality and p o s i t i v e f i n d i n g s . Thus, 84 percent of the adequately designed studies yielded positive results as compared to only 33 percent of the questionable studies. Although Meltzoff and Kornreich made a noteworthy methodological innovation, the same c r i t i c i s m can be made of th e i r work that Bergin made of Eysenck's work, that i s , that no statements can be made regarding what s p e c i f i c psychotherapy techniques are e f f e c t i v e with which p a r t i c u l a r psychological problems. Bergin, as noted above, recalculated Eysenck's treatment remission rates and found a number of discrepancies. In addition, Bergin reviewed 52 studies of psychotherapy outcome. He judged 22 to be p o s i t i v e , 15 to be negative, and 15 to be equivocal. On the basis of these analyses and his reanalysis of Eysenck's data, Bergin concluded that psychotherapy has moderately positive r e s u l t s . Rachman (1973), a frequent collaborator of Eysenck, then reanalyzed and crit i q u e d Bergin's work. He disallowed a number of studies because the subjects were c l a s s i f i e d as delinquent or psychosomatic rather than neurotic. Rachman analyzed 23 studies which he selected as appropriate to assess the effectiveness of \"verbal\" psychotherapy. Of these studies, Rachman found only one that provided tentative evidence of p o s i t i v e results and f i v e that produced negative r e s u l t s . Smith et a l . (1981) have c r i t i c i z e d Rachman on the grounds that he s e l e c t i v e l y chose studies to review which would support his bias. Rachman excluded 17 studies for a variety of reasons; of these, only two showed negative effects. Smith et a l . also c r i t i c i z e d Rachman for selective exclusion of studies on methodological grounds; they argued that he should have followed Meltzoff and Kornreich's procedure and compared the well-designed with the poorly-designed studies to determine whether they yielded d i f f e r e n t kinds of conclusions. Luborsky, Singer, and Luborsky (1975) used a box-score analysis, ranking each study on a five-point scale of research quality. They then categorized study r e s u l t s as showing s i g n i f i c a n t l y better results for the treatment group, for the comparison group, or no s i g n i f i c a n t difference. Luborsky et a l . analyzed 33 studies i n which psychotherapy treatment groups were compared with no-treatment control groups. Of these, 20 studies had treatment groups that did s i g n i f i c a n t l y better than no-treatment groups and 13 studies showed no difference between the groups. The authors found no instances i n which the control group did s i g n i f i c a n t l y better than the treatment group. There have been no substantive c r i t i c i s m s of t h e i r work and i t has been supported by other reviews. P a r l o f f (1978) undertook an exceedingly comprehensive review of psychotherapy outcome studies for the National I n s t i t u t e of Mental Health i n which studies were organized primarily by disabling conditions. P a r l o f f ' s general finding was that p a t i e n t s t r e a t e d w i t h p s y c h o s o c i a l t h e r a p i e s (psychotherapies that do not use drug treatments) showed s i g n i f i c a n t l y more improvement than untreated patients. Furthermore, studies which controlled 31 for placebo effects found changes associated with treatment to be greater than changes associated with placebo. P a r l o f f also concluded, along with Eysenck, Rachman, Bergin, and to some extent Meltzoff and Kornreich, that there i s clear evidence that behaviour-based therapies are e f f e c t i v e for s p e c i f i c conditions. Smith and Glass ( 1977) conducted a meta-analysis of psychotherapy outcome studies; they undertook to i d e n t i f y and c o l l e c t a l l studies that tested the effects of d i f f e r e n t types of therapy, r e l a t i n g the s i z e of e f f e c t to the c h a r a c t e r i s t i c s of the therapy (e.g., diagnosis of patient, t r a i n i n g of therapist) and of the study. From 375 studies, the authors computed 833 e f f e c t signs, several studies y i e l d i n g effects on more than one type of outcome or at more than one time a f t e r therapy. The d e f i n i t i o n of the magnitude of e f f e c t - or \"ef f e c t s i z e \" - was the mean difference between treated and control subjects divided by the standard deviation of the control group: (*t - x c ) ES = SC The r e s u l t s of the a n a l y s i s i n d i c a t e d t h a t the psychotherapies represented by the available outcome evaluations move the average c l i e n t from the 50th to the 75th perce n t i l e . Smith and Glass then investigated the e f f e c t of type of therapy.. They grouped s t u d i e s i n t o ten types of psychotherapy and computed Hays' G e r i a t r i c 0.5 0. 5 0. 5 0.5 538 (2) Group Therapy 0.5 0. 5 1. 0 540 (2) Psychometric 2. 0 541 (2) Sex Issues 0.5 0. 5 0. 5 0.5 542 (2) Forensic 0.5 0. 5 0. 5 0.5 12. 5 2. 0 TOTAL 54.0 UNITS 2.0 10.0 8.5 14.5 14. 5 4.5 C l i n i c a l Experience T u t o r i a l 2 220 hours R o t a t i o n 3 5280 hours On C a l l 4 352 hours TOTAL 5852 HOURS 1U.B.C. course c r e d i t d e s i g n a t i o n s have been transformed i n t o semester u n i t s . ^Assuming 1.25 hours per week f o r an 11 month year f o r four years. ^Assuming 7.5 hours per day at four days per week f o r an 11-month year f o r fou r y e a r s. 4Assuming On-Call one day per week, c a l l e d e i g h t hours per month f o r an 11 month year f o r four years. 42 Columbia. As noted above, the student entering the psychiatry t r a i n i n g program has completed four years of t r a i n i n g i n medicine and an internship. At the University of B r i t i s h Columbia, the undergraduate t r a i n i n g can include 10-15 semester u n i t s of course w o r k \/ c l i n i c a l experience i n psychiatry. As w e l l , i f students take both the fourth-year clerkship and the specialty internship i n psychiatry, these experiences may substitute for one year of residency t r a i n i n g . The psychiatry t r a i n i n g program requires four years for completion and has both a c l i n i c a l experience component and a didactic i n s t r u c t i o n component, which continue for the length of the program. To accommodate the didactic i n s t r u c t i o n component, the program reserves one day each week for classroom i n s t r u c t i o n ; students t y p i c a l l y take two to three courses i n each of three terms. In the f i r s t year, required courses include orientation to p s y c h i a t r y , psychopathology, i n t e r v i e w and e x a m i n a t i o n of the p a t i e n t , drugs and somatic treatments, and psychological measurement. In the second year, courses include research methods i n psychiatry, neurological bases of human behavior, behavioral treatments i n psychological conditions, and c h i l d psychiatry. In the t h i r d year, courses include s o c i a l psychiatry, c l i n i c a l neurology i n psychiatry, g e r i a t r i c psychiatry, sexual i s s u e s i n p s y c h i a t r y , and forensic psychiatry. In the fourth year, as well as i n each preceding year, two courses, one i n psychotherapy and one i n group, milieu, and marital psychotherapies are given (numbered successively for each year). In a d d i t i o n , e l e c t i v e courses i n the province and f u n c t i o n s of p s y c h i a t r y , t h e o r i e s and e t i o l o g y , problems of cerebral function, behavior physiology, neurochemistry, advanced psychopharmacology, and development and learning are offered. 43 The c l i n i c a l experience component takes a number >^of forms, p r i n c i p a l of which are the residency rotation assignments. Students work s i x months i n each placement with two weeks1 holidays at the end of each rotation, making an 11-month working year. Students work i n t h e i r rotation placement four days per week, t y p i c a l l y a minimum 7.5 hour day. In addition, students are on c a l l about one day i n seven; c a l l s usually require a minimum of two hours and can require as much as s i x - eight hours to complete. Rotation placements are available i n a variety of settings: general h o s p i t a l , children's ho s p i t a l , and teaching-hospital acute and outpatient f a c i l i t i e s , c h i l d and family c l i n i c , g e r i a t r i c extended care, adolescent i n p a t i e n t and outpatient care, behavior therapy services, and sexual medicine unit. There i s also a rotation available to Prince George, a northern c i t y , which may extend from two weeks to two months. The c l i n i c a l experience component also involves the t u t o r i a l . Each student i s assigned to a psychotherapy tutor. The emphasis i n the f i r s t year i s on taking a f u l l developmental history and f o r m u l a t i n g a treatment p l a n . In succeeding years, students are encouraged to undertake long-term psychotherapy with one or two patients under the supervision of the tutor. Students meet with the tutor 1 - 1 1\/2 hours per week and a new tutor i s assigned each year. In addition to the didactic i n s t r u c t i o n and c l i n i c a l experience elements of the psychiatry t r a i n i n g program, students are encouraged but not required to become involved i n c l i n i c a l research; t h i s may take various forms, such as a s s i s t i n g a c l i n i c a l supervisor, w r i t i n g up an unusual case for publication, or designing and managing a small research study. Lastly, a l l students p a r t i c i p a t e i n study groups, which a s s i s t them to prepare f o r the RCPSC examinations for q u a l i f i c a t i o n as a medical s p e c i a l i s t i n psychiatry. (For a more detailed outline of the 44 University of B r i t i s h Columbia Psychiatry t r a i n i n g program, please refer to Appendix A.1.b.) Training i n Psychology C l i n i c a l psychology t r a i n i n g i n the majority of t r a i n i n g programs i n North America follows what i s c a l l e d the Boulder Model, a r t i c u l a t e d at a conference at Boulder, Colorado, i n 1949, when the t r a i n i n g of psychologists as applied p r a c t i t i o n e r s became a p r i o r i t y f o r U.S. funding and academic organizations. The Boulder Model recommends that c l i n i c a l psychologists should be competent both as academic researchers and as professional c l i n i c i a n s . C l i n i c a l psychology t r a i n i n g i s a post-baccalaureate program leading to the degree of Doctor of Philosophy (Ph.D.). The n a t i o n a l a c c r e d i t a t i o n body f o r Canadian c l i n i c a l psychology t r a i n i n g programs i s the Canadian Psychological Association. Accreditation standards specify three years of f u l l - t i m e course work i n s c i e n t i f i c and professional standards and ethics, research design and methodology, s t a t i s t i c s , psychological measurement, history and systems, and substantive content. General core content must i n c l u d e the b i o l o g i c a l , cognitive\/affective, social\/developmental as well as the i n d i v i d u a l bases of behavior. C l i n i c a l core courses must encompass the range of assessment and intervention techniques and t h e i r t h e o r e t i c a l bases. Research t r a i n i n g requires execution of research projects at the M.A. and Ph.D. le v e l s . C l i n i c a l t r a i n i n g requires a minimum of 600 hours of practicum experience, including 250 hours of direct service experience and 125 hours of formally scheduled supervision, and 1600 hours of internship experience, which can be taken f u l l - t i m e i n one year or h a l f - t i m e i n two years. (For a more d e t a i l e d o u t l i n e of 45 a c c r e d i t a t i o n standards f o r c l i n i c a l psychology t r a i n i n g programs, please refer to Appendix A.2.a.) Simon Fraser University i n Burnaby, B r i t i s h Columbia, offers a c l i n i c a l psychology t r a i n i n g program a c c r e d i t e d by the American Psychological Association and p r o v i s i o n a l l y accredited by the Canadian Psychological Association (see Table I I I ) . Prerequisite requirements are a B.A. degree, 24 semester credits i n the experimental areas of psychology, a s t a t i s t i c s course, and satisfactory scores on the Graduate Record Examination. Students are permitted three years to complete the M.A. degree and four years to complete the Ph.D. degree. Students work 11 months per year. The program does not offer a \"terminal\" M.A. degree i n c l i n i c a l psychology; rather, students receive a master's degree i n psychology and are then admitted to the Ph.D. program i n c l i n i c a l psychology. In the M.A. p o r t i o n of the program, students are required to complete two of the three general core courses i n the b i o l o g i c a l , 1 cognitive\/affective, and social\/developmental bases of behavior, three courses i n research design, and a course i n personality theory. The student must also complete f i v e core c l i n i c a l courses: psychopathology, i n d i v i d u a l assessment techniques (two semesters), and i n t e r v e n t i o n techniques (two semesters). As w e l l , the student must complete three c l i n i c a l placements: i n d i v i d u a l assessment practicum (two semesters; 60 hours), intervention practicum (two semesters; 85 hours), and summer practicum (four months f u l l - t i m e ; 600 hours). In addition, the student must complete an M.A. thesis. In the f i r s t year of the Ph.D. program, students take t h e i r t h i r d general core course, a course i n ethics and professional issues, two courses i n advanced topics ( c l i n i c a l assessment, c l i n i c a l intervention, TABLE III Program Elements : S.E.U. C l i n i c a l Psychology Training Program PROGRAM ELEMENTS Research General Course Work Methods Core C l i n i c a l Core Pathol ogy Assessment Psychotherapy General Psychometric 600 (5) Bio l . Bases 5.0 601 (5) Cog\/Aff.Bases 5.0 602 (5) Dev\/Soc.Bases 5.0 744 (3) Pathology 3.0 770 (3) Personallty 3.0 806 (3) Adv.Assess. 3.0 807 (3) Adv.tnterven. 0.5 0.5 2.0 819 (2) Ethics\/Prof. 2.0 820 (6) Assessment 6.0 822 (6) Intervention 1.5 1.5 3.0 824 (3) Clin.Res.Des. 3.0 910 (5) Res.Design 5.0 911 (5) Res.Design 5.0 2.0 9.0 TOTAL 54.0 WITS 13.1 17.0 8.0 11.0 5.0 Research Projects M.A. Thesis 12.0 units Ph.D. Thesis 36.0 units TOTAL 48.0 UNITS Comprehensive Exam yes C l i n i c a l Experience Psychometric Assess. 60 hones; Psychotherapy 84 hours' Practicum 600 hours Internship 1600 hours TOTAL 2344 HOURS ^Assuming 2 hours per week for 12 weeks in the f i r s t semester and 3 hours per week for 12 weeks in the second semester. ^Assuming 4 hours per week for 12 weeks in the f l t s t semester and 3 hours per week for 12 weeks in the second semester. 47 program evaluation, or i n d u s t r i a l psychology), and the comprehensive examination on the previous three years' material- In the succeeding years of the Ph.D. program, students are required to complete a Ph.D. dissertation and an internship (one year f u l l - t i m e or two years h a l f -time; 1600 hours). (For a more detailed outline of the Simon Fraser University c l i n i c a l psychology t r a i n i n g program, please r e f e r to Appendix A.2.b.) Training i n Psychiatric Nursing Psychiatric nursing t r a i n i n g i s a post-secondary program leading to the degree of Diploma of Associate i n Psychiatric Nursing. Psychiatric nursing t r a i n i n g programs are accredited by the p r o v i n c i a l r e g i s t r a t i o n bodies f o l l o w i n g g u i d e l i n e s developed i n a s s o c i a t i o n w i t h the P s y c h i a t r i c Nurses Association of Canada. In B r i t i s h Columbia, the psychiatric nursing t r a i n i n g program i s accredited by the Registered Psychiatric Nurses Association of B r i t i s h Columbia. In Canada, t r a i n i n g programs are also available i n Alberta, Saskatchewan, and Manitoba and these programs are accredited, respectively, by the PNAA, SPNA, and RPNAM. Accreditation standards specify a program length of 20 months of classroom i n s t r u c t i o n and c l i n i c a l placements. The minimum acceptable requirement for t h e o r e t i c a l i n s t r u c t i o n i s 750 hours, which must include a minimum of 225 hours of basic nursing and 450 hours of psychiatric nursing, including 36 hours r e l a t i n g to mental retardation. (For the accreditation standards for psychiatric nursing programs, please refer to Appendix A.3.a.) Douglas College i n New Westminster, B r i t i s h Columbia, offers a psychiatric nursing t r a i n i n g program accredited by the RPNABC (see Table IV). The objective of the program i s to t r a i n graduates who w i l l be TABLE IV Program Elements: Douglas College P s y c h i a t r i c Nursing T r a i n i n g Program PROGRAM ELEMENTS Course Work General Core C l i n i c a l Core B a s i c Psych. Nursing Nursing Pathology Assessment Psychotherapy Pharmacotherapy NUR 100 (4 0) Nur.Theory 4 0 NUR 102 (1 5) pharmacology 1 5 NUR 103 (1 5) I n t e r a c t i o n 1 5 NUR 200 (4 0) Nur. Theory 4 0 NUR 202 ( 1 5) Pharmacology 1 5 NUR 203 (1 5) I n t e r a c t i o n 1 5 NUR 300 (4 0) Nur. Theory 4 0 NUR 303 (3 0) I n t e r a c t i o n 3 0 NUR 304 (1 5) Health Promo. 1 5 BIO 103 (3 0) Physiology 3 0 BIO 20 3 (3 0) Physiology 3 0 PSV 100 (3 0) psychology 3 0 PNU 450 (5 0) Theory Adult 1 0 PNU 460 (3.0) Indiv. Therapy PNU 550 (2 0) Theory Men.Ret. PNU 551 (2 5) Care Men.Ret. PNU 555 (2 0) Care E l d e r l y PNU 560 (3 0) Group Therapy PNU 570 (1 5) Leadership 1 5 PNU 650 (3 0) Psy.Nur.Theory 1 0 COM 170 (3 0) prof. W r i t i n g 3 0 28 5 9 5 TOTAL 56.5 UNITS 38.0 1.0 1.0 1.0 1.0 0.5 0.5 2.0 0.5 0.5 0.5 0.5 0.5 0.5 1.0 0.5 0.5 0.5 0.5 0.5 0.5 0.5 2.0 0.5 0.5 0.5 0.5 4.0 4.0 7.5 3.0 C l i n i c a l Experience B a s i c Nursing Laboratory 168 hours Placement 465 hours Psych. Nursing Placement 285 hours preceptorship 370 hours TOTAL 12BB HOURS 49 able t o provide s a f e , comprehensive p s y c h i a t r i c n u r s i n g care to individuals i n acute and long-term p s y c h i a t r i c , psychogeriatric, mental retardation, extended and intermediate care settings. I t i s expected that the graduate w i l l be able to u t i l i z e beginning leadership s k i l l s i n delegating, organizing, and coordinating nursing care at the nursing team l e v e l . I t i s not expected that graduates w i l l be able to function i n specialty areas such as c h i l d , adolescent, forensic, and community care settings without additional t r a i n i n g . I t i s understood that while i n some other provinces and i n the United States, more advanced t r a i n i n g programs i n psychiatric nursing are available, i n B r i t i s h Columbia the psychiatric nursing program prepares beginning p r a c t i t i o n e r s . Thus, i n order to work i n specialty areas, graduates w i l l need intensive i n -service t r a i n i n g by the employer i n the s p e c i f i c job placement and\/or upgrading to the degree of Bachelor of Science i n Nursing (B.S.N.) with a s p e c i a l t y i n p s y c h i a t r y or a B.A. degree i n one of the s o c i a l sciences. I t i s t h i s l a t t e r q u a l i f i c a t i o n of a B.S.N, or B.A. degree which i s u s u a l l y required for employment i n the senior psychiatric nursing p o s i t i o n s i n community mental h e a l t h centres. However, p s y c h i a t r i c nurses with the basic Diploma degree are also presently employed i n junior p o s i t i o n s i n mental h e a l t h centres i n B r i t i s h Columbia; hence, I have documented psychiatric nursing t r a i n i n g only to the l e v e l of the Diploma degree. Prerequisite requirements for the Douglas College program are a secondary degree (\"C\" average with two Grade 11 or Grade 12 science courses), I n d u s t r i a l F i r s t Aid C e r t i f i c a t e or both CPR and F i r s t Aid C e r t i f i c a t e s , medical assessment showing adequate p h y s i c a l h e a l t h , s a t i s f a c t o r y chest X-ray, current immunization c e r t i f i c a t e , and satisfactory performance on the Douglas College entrance examinations. 50 The program requires two f u l l years of s i x consecutive semesters (21 months) to complete. The f i r s t year i s taken i n common with students i n the general nursing program and provides a foundation for the second year, which concentrates on t r a i n i n g s p e c i f i c to psychiatric nursing. In the f i r s t year, students take three semesters of courses i n nursing theory, introducing students to the nursing care of the well adult and the el d e r l y , as w e l l as a d u l t s i n medical, s u r g i c a l , and acute care settings. Students also take three semesters of courses i n nursing interactions, which focus on communication approaches with patients i n these same care settings, including interviewing, patient teaching, and group process s k i l l s . As w e l l , students take two semesters of courses i n pharmacology and anatomy\/physiology and one semester of courses i n introductory psychology and health promotion. C l i n i c a l experience i s provided i n each semester through a nursing laboratory, where students must master selected nursing s k i l l s before p r a c t i c i n g i n the care settings, and through c l i n i c a l placements for a t o t a l of 645 hours of c l i n i c a l experience. In the second year, students take f i v e courses i n psych i a t r i c nursing theory, which introduce students to psychiatric terminology, d i a g n o s t i c c l a s s i f i c a t i o n s , psychopathology, assessment, intervention techniques (psychotherapy and pharmacotherapy), l e g a l and c l i n i c a l issues, and professional roles and r e s p o n s i b i l i t i e s . The f i r s t theory course, d e a l i n g with the care of a d u l t s i n acute and long-term psychiatric settings, requires one semester to complete and the next three theory courses, dealing with the care of the mentally handicapped and the eld e r l y , each require a half-semester to complete. The f i n a l intensive one-week course i n psychiatric nursing theory brings together 51 the material i n the preceding courses and focusses on the role of the psychiatric nurse as a change agent within the mental health service delivery system. In addition\/ students take two courses i n psychi a t r i c nursing intervention; these courses prepare the student to provide in d i v i d u a l and group counselling to patients i n i n s t i t u t i o n a l settings. As well\/ students take one course i n leadership, which prepares the student to function i n the role of program coordinator i n a variety of treatment modalities and as a head nurse. C l i n i c a l experience i n psychiatric nursing practice i s required i n each semester. The f i r s t c l i n i c a l experience provides 195 hours of practice i n an acute adult psychiatric setting. The second c l i n i c a l experience provides 90 hours of practice i n g e r i a t r i c and psychogeriatric s e t t i n g s . The t h i r d c l i n i c a l experience, the preceptorship, provides 370 hours of f u l l - t i m e practice i n one of the various types of mental health settings for which t h e i r t r a i n i n g has prepared the students. (For a more detailed outline of the Douglas College psychiatric nursing t r a i n i n g program, please refer to Appendix A.3.b.) Training i n Social Work There are three degree programs i n s o c i a l work t r a i n i n g i n Canada, the Bachelor of Social Work, the Master of Social Work, and the Doctor of S o c i a l Work. The B.S.W. and M.S.W. degrees are considered more appropriate for students wishing to pursue s o c i a l work practice and the D.S.W. i s considered more appropriate for students wishing to pursue an academic career. As noted above, I have chosen to consider the B.S.W. and M.S.W. programs together as the t r a i n i n g program standard for s o c i a l workers p r a c t i c i n g i n the mental h e a l t h f i e l d . The n a t i o n a l accreditation body for Canadian s o c i a l work t r a i n i n g programs i s the 52 Canadian Association of Schools of Social Work. Rather than enforce a single curriculum model, the CASSW has made a more general statement of standards i n the b e l i e f that t h i s approach w i l l encourage the c r e a t i v i t y of i n d i v i d u a l schools. Thus, proportionately greater importance i s attached to a c l e a r statement of program objectives and curriculum design by schools seeking accreditation. The accreditation standards state the central philosophical requirement for program accreditation as follows: \"Schools s h a l l infuse s o c i a l work values and ethics into the c u r r i c u l u m , i n c l u d i n g f i e l d p r a c t i c e . More s p e c i f i c a l l y , schools are expected to promote a professional commitment to optimize the d i g n i t y and p o t e n t i a l of a l l people. To t h i s end, schools are expected to provide education enabling p r o f e s s i o n a l action to remove obstacles to s o c i a l functioning and to eliminate inequality.\"2 Accreditation standards for the B.S.W. t r a i n i n g program specify that the graduate w i l l be prepared for general practice- The curriculum must offer the student opportunities to become fa m i l i a r with the development of Canadian s o c i a l welfare i n s t i t u t i o n s , the history of the profession of s o c i a l work, the values and assumptions associated with s o c i a l problems, and the u t i l i z a t i o n of s c i e n t i f i c methods i n p r o f e s s i o n a l i n t e r v e n t i o n . The t r a i n i n g program must include a f i e l d practice component which r e f l e c t s the school's objectives and which prepares for professional practice. Accreditation standards for the M.S.W. program specify that entering students must be able to demonstrate competence at the B.S.W. l e v e l . Studies at the M.S.W. l e v e l should be focussed, emphasizing the relationship among s o c i a l work problems, intervention approaches, s o c i a l s e r v i c e systems, and the s o c i a l and p o l i t i c a l context. The t r a i n i n g program must p r o v i d e f i e l d placement opportunities which demand an advanced l e v e l of professional judgement 53 and intervention s k i l l s . (For a more detailed outline of accreditation standards for s o c i a l work t r a i n i n g programs, please refer to Appendix A. 4.a. ) The University of B r i t i s h Columbia i n Vancouver, B r i t i s h Columbia, offers s o c i a l work t r a i n i n g programs accredited by the CASSW at both the B. S.W. and the M.S.W. levels (See Table V). The School of Social Work states the objectives of the B.S.W. program as \"to provide students with the knowledge and s k i l l s necessary to beginning professional practice i n s o c i a l work roles at the i n d i v i d u a l , family and small group or community l e v e l [and] to prepare selected students for entry into more advanced professional studies at the graduate level.\"3 The B.S.W. program i s offered i n three formats: a two-year (16 months) undergraduate program for students without a B.A. degree, a one-year (8.5 months) graduate program for students with a B.A. degree and extensive s o c i a l work employment, and a two-year (16 months) graduate program for students with a B.A. degree but minimal previous s o c i a l work employment. Prerequisite requirements for the undergraduate B.S.W. program are completion of the f i r s t two years of the B.A. program with a minimum 65 percent average, 12 semester u n i t s i n the s o c i a l and behavioral sciences, and a s t a t i s t i c s course (optional p r e r e q u i s i t e , degree requirement). Prerequisite requirements for the graduate B.S.W. program are a B.A. degree, 24 semester u n i t s i n the s o c i a l and behavioral sciences, a s t a t i s t i c s course, and satisfactory performance on the Faculty of Arts English Composition Tests. Degree requirements for the undergraduate and graduate B.S.W. programs are the same with the exception that undergraduate students must complete an additional 15 semester units i n the s o c i a l and behavioral sciences. TABLE V Program Elements: U.B.C. S o c i a l Work T r a i n i n g Program 1 PROGRAM ELEMENTS Research General Methods Core COURSE WORK B.S.W. Program 300 (6) 310 (6) 320 (6) 336 (3) 400 (3) 410 or 415 (6) M.S.W. Program 512 (6) 522 (6) 542 (6) 552 (6) 560 (6) C l i n i c a l Core Cdn. Soc. Ser. In t e r v e n t i o n Research Meth. S o c i a l Problems Cdn. Soc. Ser. Int e r v e n t i o n Health Problems Can. H l t h . Ser. Int e r v e n t i o n Research Meth. I n t e r v e n t i o n TOTAL 5B.5 UN ITS Research P r o j e c t - 320 1.5 un l t a Major Paper yes Comprehensive Exam yes C l i n i c a l Experience Pathology Assessment Psychotherapy 6.0 1. 5 1.5 3.0 4.5 3. 0 3.0 1. 5 1.5 3.0 6. 0 6.0 1. 5 1.5 3.0 6.0 1. 5 1.5 3.0 10.5 15.0 15. 0 6-0 12.0 B.S.W. {1 y e a r ) 2 B.S.W. (2 y e a r ) 3 M.S.W.4 TOTAL 510 hours 960 hours 4B0 hours 990-1440 BOORS 'u.B.C. course c r e d i t d esignations have been transformed i n t o semester u n i t s . 2Assuming 7.5 hours per day at 2 days per week f o r 8.5 months. 3Assuming 7.5 hours per day at 2 days per week f o r 16 months 4Assuming 7.5 hours per day at 2 days per week f o r 8 months. 55 Students i n the B.S.W. program are required to take three general core courses i n s o c i a l work theory. These courses review the structure of Canadian s o c i a l s e r v i c e s , examining the l e g i s l a t i o n r e l a t i n g to so c i a l issues, the tran s l a t i o n of t h i s l e g i s l a t i o n f i r s t i n to s o c i a l p o l i c y and then into s o c i a l programs, and f i n a l l y , the impact of these s o c i a l programs on the in d i v i d u a l . Using a systems model, students study the interactions between the s o c i a l context and the i n d i v i d u a l , i d e n t i f y i n g the values which underlie s o c i a l policy development. As we l l , students must take two courses i n s o c i a l work research methods and complete a small research project. The c l i n i c a l core courses include a course i n s o c i a l pathology, which examines the dynamics of human behavior within s o c i a l systems, focussing on par t i c u l a r s o c i a l problems such as divorce, i l l n e s s , and poverty. Students are also required to complete three courses i n s o c i a l work intervention, learning assessment techniques and i n t e r v e n t i o n s t r a t e g i e s . The c l i n i c a l experience component of the program requires the student to work two days per week i n a c l i n i c a l , placement. Students i n the one-year graduate program complete 510 hours of F i e l d Instruction and students i n the two-year undergraduate and graduate programs complete 960 hours of F i e l d Instruction. (For a more detailed outline of the University of B r i t i s h Columbia B.S.W. s o c i a l work t r a i n i n g program, please refer to Appendix A.4.b(1).) The M.S.W. program r e q u i r e s ten months of f u l l time work to complete. The M.S.W. prerequisite requirement i s a B.S.W. degree. The program o f f e r s a problem-centered curriculum through a choice among three concentrations: family needs, health needs, and socio-economic needs. Within the concentration, the student then chooses among four p r a c t i c e s p e c i a l i z a t i o n s : d i r e c t p r a c t i c e , s o c i a l p lanning and 56 community work, s o c i a l administration, and research. For purposes of the present comparison, I have assumed that the student planning to work i n mental health service settings would be most l i k e l y to choose the health needs concentration with a direct practice s p e c i a l i z a t i o n . Given t h i s assumption, the student would be required to take two general core courses i n s o c i a l work theory, si m i l a r to the s o c i a l work theory courses at the B.S.W. l e v e l but dealing s p e c i f i c a l l y with health care p o l i c y , financing, and delivery. Six c l i n i c a l core courses are required. Two courses present s o c i a l pathology theory, analyzing theories on health and i l l n e s s as these affect s o c i a l work i n t e r v e n t i o n and studying s e l e c t e d h e a l t h problems f o r t h e i r s o c i a l work implications. Two courses present methods of s o c i a l work direct practice and two courses present further s p e c i a l i z a t i o n i n direct practice techniques i n the student's interest area. As w e l l , students must take two courses i n r e s e a r c h methods and complete a major paper and comprehensive examination. The c l i n i c a l experience component of the s o c i a l work t r a i n i n g program requires the student to work two days per week i n a c l i n i c a l placement f o r eight months, p r o v i d i n g s t u d e n t s w i t h approximately 480 hours of c l i n i c a l experience. (For a more detailed outline of the University of B r i t i s h Columbia M.S.W. s o c i a l work t r a i n i n g program, please refer to Appendix A.4.b.(2).) 4.2 PROFESSIONAL TRAINING PROGRAMS COMPARED I t i s apparent from the review of professional t r a i n i n g standards and professional t r a i n i n g programs presented i n Tables I - V and i n the text, that a l l the t r a i n i n g programs provide both didactic i n s t r u c t i o n and c l i n i c a l experience i n the treatment of mental disorders. However, the programs vary i n the emphasis they place on treatment modes, patient 57 populations, and treatment settings. Psychiatrists are p a r t i c u l a r l y well-trained i n somatic treatments and i n p s y c h i a t r i c d i a g n o s t i c c l a s s i f i c a t i o n . Psychologists receive a great deal of t r a i n i n g i n normal psychological processes and i n c r i t i c a l analysis of methodology. Social workers are trained to view themselves and t h e i r c l i e n t s i n a s o c i a l context and to develop s o c i a l solutions to s o c i a l problems. P s y c h i a t r i c nurses are trained to intervene d i r e c t l y with mentally disordered and handicapped patients i n i n s t i t u t i o n a l settings. Thus, while the t r a i n i n g programs overlap i n some respects, they d i f f e r i n others. Let us begin by examining the points of most extreme divergence and then gradually move toward those areas of s i m i l a r i t y which are of concern to us i n the present context. Each of the professions comes from a different t r a d i t i o n . For example, comparing psychiatry and psychology, psychiatry's development has been much more related to service delivery than to research, and psychology's has been the reverse. This difference i s ref l e c t e d i n the figures i n Table I where we can see the r e l a t i v e l y greater weight given i n the psychiatry t r a i n i n g program to psychotherapy, pharmacotherapy, and c l i n i c a l experience and the r e l a t i v e l y greater weight given i n the psychology t r a i n i n g program to research methods and research experience. Differences also occur i n the choice of assessment techniques. Both programs devote considerable time to assessment, however, psychiatry's emphasis i s toward c l i n i c a l c l a s s i f i c a t i o n while psychology's emphasis i s toward b e h a v i o r a l a n a l y s i s ; l i k e w i s e , p s y c h o l o g i s t s spend proportionately less time learning patient examination s k i l l s and more time learning the administration and interpretation of psychometric test s . Kiesler (1979) presents an i n t e r e s t i n g commentary on how these 58 d i f f e r e n c e s manifest themselves when comparing the a t t i t u d e s of ps y c h i a t r i s t s and psychologists toward service review: \"I think i t i s f a i r to say that ps y c h i a t r i s t s have b u i l t t h e i r review system on the t r a d i t i o n a l medical one. The t r a d i t i o n a l medical one i s a retrospective review system based on the assumption that there are accepted and t r a d i t i o n a l s t a n d a r d s and methods of p r a c t i c e . P s y c h i a t r i s t s ' orientation i s to weed out some small percentage of people and\/or practices not meeting those standards. I have no argument with t h i s ; i t i s p e r f e c t l y plausible. But psychologists' ideas about standards of review are much more l i k e l y to be either concurrent or prospective. A psychologist dwells less on whether the method i s t r a d i t i o n a l l y accepted and more on whether the method worked. In t h i s view, the professional should state i n advance of treatment what the patient's problem i s , what treatment i s recommended, and what s p e c i f i c a l l y i s predicted to be the outcome of the treatment. I t i s rather s c i e n t i f i c and evaluative, but psychologists see t h i s as a review. I t i s more of a review of a system of treatment than i t i s a review of an i n d i v i d u a l p r a c t i t i o n e r . When discussing the i d e a l P r o f e s s i o n a l Standards Review Organization (PSRO), conversations between a p s y c h i a t r i s t and a psychologist can become q u i t e animated because they are r e a l l y t a l k i n g about q u a l i t a t i v e l y different types of review . (p.33).\" Social work's emergence as. a profession comes from a t r a d i t i o n of advocacy for the s o c i a l l y disadvantaged. Through i t s general core courses, the s o c i a l work t r a i n i n g program places heavy emphasis on knowledge of s o c i a l systems. The c l i n i c a l core courses devote r e l a t i v e l y greater time to s o c i a l pathology courses concerned with a n a l y z i n g the s o c i a l context of i n d i v i d u a l problems and devote r e l a t i v e l y less time to assessment courses concerned with techniques for i n d i v i d u a l assessment. In the area of research methods, the s o c i a l work t r a i n i n g program places almost as much emphasis on research methods as does the psychology t r a i n i n g program; however, the interest i s more i n the q u a l i t a t i v e research models rather than the quantitative models favored by psychology and, although a research project i s required, the 59 thrust i s more toward understanding how to use research findings than on producing research i t s e l f . The profession of psychiatric nursing comes from a t r a d i t i o n of direct care givers i n mental i n s t i t u t i o n s , f o r many years c a l l e d \"keepers.\" However, as the concept of the asylum changed to that of the hos p i t a l , the profession of psychiatric nursing developed; the B r i t i s h Columbia p r o v i n c i a l mental h o s p i t a l graduated i t s f i r s t class of psychiatric nurses i n 1932. With the community mental health movement, there has been an exodus of patients from the large i n s t i t u t i o n s and an accompanying greater demand on p s y c h i a t r i c nurses f o r independent practice and therapeutic rather than custodial s k i l l s . The psychiatric nursing t r a i n i n g program r e f l e c t s t h i s expectation that p s y c h i a t r i c nurses w i l l f u n c t i o n both as d i r e c t care givers under medical supervision and as independent change agents i n the considerable weight given i n the f i r s t year to basic nursing s k i l l s and the emphasis within the second year on psychotherapy intervention techniques. Granting these differences i n the tr a d i t i o n s and t r a i n i n g of the four core mental health professions, the data summarized i n Table I i n d i c a t e that there i s also a great deal of s i m i l a r i t y . A l l four professions receive didactic i n s t r u c t i o n i n pathology, assessment, and psychotherapy and also c l i n i c a l experience i n the treatment of the mentally disordered. The t r a i n i n g programs prepare a l l four professions t o f u n c t i o n as p s y c h o t h e r a p i s t s : p s y c h i a t r i s t s , psychologists, and s o c i a l workers as independent practitioners across a l l s e t t i n g s and p s y c h i a t r i c nurses as independent p r a c t i t i o n e r s i n s e l e c t e d circumstances. The t r a i n i n g program data indicate that none of the four professions can claim proprietary rights to the body of knowledge and experience which prepares the student t o become a p r a c t i c i n g 60 psychotherapist. In the following two chapters, we w i l l examine the licensure standards granting p r i v i l e g e s or imposing l i m i t a t i o n s on the four professions as psychotherapists and then review the l i t e r a t u r e comparing t h e i r r e l a t i v e effectiveness as psychotherapists. 61 CHAPTER FIVE THE PROFESSIONAL LICENSURE STANDARDS Chapter Five presents a review of professional licensure standards and professional practice p r i v i l e g e s for the four core mental health professions i n the province of B r i t i s h Columbia. Professional l i c e n s i n g standards are summarized i n Table VI and professional practice p r i v i l e g e s are summarized i n Table VII. The chapter concludes with a comparison of licensure standards and practice p r i v i l e g e s among the four professions and a d i s c u s s i o n of l e g i s l a t i o n i n other j u r i s d i c t i o n s which has granted more extensive practice p r i v i l e g e s to psychologists than i s presently the case i n B r i t i s h Columbia. In discussing professional licensure standards, I have drawn a d i s t i n c t i o n between l i c e n s u r e s t a t u t e s and r e g i s t r a t i o n s t a t u t e s . In l i c e n s u r e l e g i s l a t i o n , a profession i s given the power to control t i t l e , to define the scope of practice, and to enforce e x c l u s i v e p r a c t i c e p r i v i l e g e s . In r e g i s t r a t i o n l e g i s l a t i o n , the profession i s given the power to control t i t l e and to define practice but not to enforce exclusive practice p r i v i l e g e s . 5.1 PROFESSIONAL LICENSURE STANDARDS Psychiatry In B r i t i s h Columbia, psyc h i a t r i s t s are licensed under the Medical Practitioners Act (R.S.B.C. 1979, c 254). The act gives the College of P h y s i c i a n s and Surgeons of B r i t i s h Columbia (CPSBC) the power to register members, to establish a code of ethics, and to d i s c i p l i n e members (s.29(1), s.4, s.48, s.50, and s.51). TABLE VT Licensure Standards Far Mental Health Professions in British Qoluibla PROFESSuTi PSYCHXAlRf PSYCHOLOGY PSYCHIATRIC NURSItG SOCIAL WORK fui*i r>\\ n)-f*r\\ TVJ Body College of Physicians British Columbia Registered Psychiatric Board of Registration Associated Professional (Proposed) Board of and Surgeons of British Psychological Associa- Nurses Association of far Social Workers of Social Workers of Social Work Examiners Colmbia tion British Columbia tlie Province of B.C. British Columbia Itajilrud Anmrtaf nd Society British Columbia Associ-H r i e m t i t p None None None ation of Social Workers None None htelical Practitioners Psychologists Set Unrses (Registered Sncial Workers (Regis- (Proposed) Social Work Inginlariae Act Act (R.S.B.C. 1979, (R.S.B.C., 1979, Psychiatric) Act tration) Act (R.S.B.C. Act c. 254) c. 342) (R.S.B.C. 1979, c. 301) 1979, c. 389) None T i t l e Fellow of the Royal Col-\u2022 Psychologist or Registered Psychiatric Registered Social Social Worker legs of Physicians and Registered Psychologist Nurse (R.P.N.) Worker (R.S.W.) Licensed Social Worker Surgeons of Canada, licensed Clinical S.W. Physician and Surgeon None Licensed S.W. Spedalist Control of Title Yes Yes Yes Yes (limited) None Yes $500 for each day of Fine far I l l e ^ l Use of Title $500 contravention $2,000 $50 None $500 Practice htedicine Psychology Psychiatric Nursing Social Work Social Work Social Work Independent Practice Yes Yes Yes Yes Yes Yes Definition of Practice Yes Yes Unspecified Unspecified Unspecified Yes Control of Practice Yes None None None None None Qiixcpractxirs, Dentists, Physicians, Registered Physicians, Attorneys, Naturopaths, Optome- Professions, Academic Psychologists, Clergy, Exempted Professions trists, Pharmacists, podiatrists. Psycholo-gists, Nurses Psychologists, Government Employees Unspecified Unspecified Unspecified Other professional Groups Dade of Ethics Yes Yes Yes Yes Yes Yes Disciplinary powers: re Meabers yes Yes Yes Yes Yes Yes Offence Act (R.S..B.C. Prosecution for Illegal 1979, c. 304) Fine and\/ None None None None None Practice or Imprisonment Procedure Degrees i n Rarttfllrr of Degrees in Bachelor of Degrees in Bachelor of Specialty Residency Doctoral Degree i n Diplcina of Associate Social Work or Master Social Work or (taster Social Work or Master Credentials \u2022Raining in Psychiatry Psychology in Psyciiiatric Nursing of Social Mark or Cne-Year Full Time Employ-ment in Social Work of Social Work of Social Work Specialty Examination Examination in the Pro- RPMABC Registration Private Practice Rajuired but unspecified Examination in Psychiatry fessional practice of Psychology Examination Itoiie Examination Royal CollegE: of Physi- Association of State Registered psychiatric Associated Professional Board of Social Work Examining Body cians and Surgoons of Canada Psychology Boards Nurses Association of British Coluihia None Social Workers of British Coluiiiia Examiners Written Examination Yes Yes Yes None None Unspecified Oral Examination Yes Yes None None Yes Unspecified ON The act gives the CPSBC the power to define the scope and control the practice of medicine. Under the act, the CPSBC has the power to fin e individuals who attempt to obtain licensure fraudulently (s.82) and to lay charges under the Offence Act (R.S.B.C 1979, c 305) against unlicensed individuals who p r a c t i c e or o f f e r to p r a c t i c e medicine (s.83). Hence, the act gives the CPSBC control of the t i t l e s \"Physician and Surgeon\" and \"Medical P r a c t i t i o n e r \" and makes l i c e n s u r e a requirement for practice. However, although the act i s quite powerful i n that i t permits the CPSBC to define the scope of practice, the act also includes an exemption section l i s t i n g other registered professions e n t i t l e d to practice t h e i r professions without being considered to be p r a c t i c i n g medicine; of p a r t i c u l a r relevance here are the sections exempting psychologists (s.73(i)) and nurses (s.73(m)). In order to become licensed as a p s y c h i a t r i s t i n B r i t i s h Columbia, the applicant must present to the CPSBC proof of the necessary academic credentials (M.D. degree, i n t e r n s h i p , and residency training) and evidence of satisfactory performance on the required examinations (Medical Council of Canada Qualifying Examination i n the specialty of psychiatry). (For statutory references, please refer to Appendix B.1.) Psychology In B r i t i s h Columbia, p s y c h o l o g i s t s are r e g i s t e r e d under the Psychologists Act (R.S.B.C. 1979, c. 342). The act gives the B r i t i s h Columbia Psychological Association (BCPA) the power to register members, to establish a code of ethics, and to d i s c i p l i n e members (s.6(1)(a), s.6(1)(d), and s.9). The act specifies that psychologists are e n t i t l e d to practice independently of the supervision of a medical prac t i t i o n e r (s.15). The act gives the BCPA control of the t i t l e s \"Psychologist\" and 64 \"Registered Psychologist\" (s.16(2)) and the power to f i n e individuals who use the t i t l e i l l e g a l l y (s.16(5)). Registration i s a requirement for employment or private practice when the t i t l e i s used (s.16(1)). The act provides a d e f i n i t i o n of the practice of psychology (s.1) but does not give the BCPA the power to enforce exclusive control of practice. The act includes an exemption section permitting practice by other registered professions, academic psychologists employed under the U n i v e r s i t y Act (R.S.B.C. 1979, c- 419), and employees of government agencies where q u a l i f i c a t i o n s i n psychology are a c o n d i t i o n of employment (s.18). In order to become registered as a psychologist i n B r i t i s h Columbia, the applicant must present to the BCPA proof of the required academic credentials (Ph.D. degree i n psychology), supervised c l i n i c a l internship (1600 hours), and satisfactory performance on the Examination i n the Practice of Professional Psychology. (For statutory references, please refer to Appendix B.2.) Psychiatric Nursing In B r i t i s h Columbia, psychiatric nurses are registered under the Nurses (Registered Psychiatric) Act (R.S.B.C. 1979, c 301). The act gives the Registered Psychiatric Nurses Association of B r i t i s h Columbia (RPNABC) the power to register psychiatric nurses, to establish a code of ethics, and to d i s c i p l i n e members (s.6(1), s.7(1)(a), and s.7(1)(b)). The act gives the RPNABC control of the t i t l e \"Registered Psychiatric Nurse\" and of the abbreviation \"R.P.N.\" (s.12(1)) and the power to fine individuals who use the t i t l e i l l e g a l l y (s.12(2)). The act does not give the RPNABC the power to define the scope of practice or to control practice; hence, i t i s the case that Registered Nurses, who may not have R.P.N, academic credentials or r e g i s t r a t i o n , are frequently employed i n 65 psychiatric nursing positions. However, r e g i s t r a t i o n i n some branch of nur s i n g i s a requirement for employment as a psychiatric nurse and although maintenance of r e g i s t r a t i o n has not been a condition of continued employment, i t i s expected t h i s l a t t e r circumstance w i l l be changed shortly (Stewart, 1986). In order to become registered as a psychiatric nurse i n the province of B r i t i s h Columbia, the applicant must present proof of the necessary academic credentials (Diploma of Asso c i a t e i n P s y c h i a t r i c N u r s i n g ) t o the RPNABC and p e r f o r m s a t i s f a c t o r i l y on the written examination set by the RPNABC. (For statutory references, please refer to Appendix B.3.) Social Work In B r i t i s h Columbia, s o c i a l workers may become registered under the Social Workers (Registration) Act (R.S.B.C. 1979, c. 389). The act gives the B r i t i s h Columbia Association of Social Workers (BCASW) the power to register s o c i a l workers, to establish a code of ethics, and to d i s c i p l i n e members (Social Workers (Registration) Act Regulations, B.C. Reg. 45\/69, s.1(2), s.2(2)(c), and s.6). The act gives the BCASW control of the t i t l e \"Registered Social Worker\" and of the abbreviation \"R.S.W.\" (B.C. Reg.45\/69, s.1(3)) and the power to fine individuals who use the t i t l e i l l e g a l l y (R.S.B.C. 1979, c. 389, s.5). The act specifies that no registered s o c i a l worker, who does not hold an M.S.W. degree, may establish a private practice. However, r e g i s t r a t i o n i s not a requirement for employment and hence, t h i s power to r e g i s t e r and to c o n t r o l t i t l e i s l a r g e l y meaningless. The B r i t i s h Columbia p r o v i n c i a l government hires many individuals i n t o positions with the c l a s s i f i c a t i o n of \"Social Worker\" who have no t r a i n i n g i n s o c i a l work but who may have a bachelor's degree 66 i n a s o c i a l science or who have trained as teachers, psychiatric nurses, or master's degree l e v e l psychologists. As w e l l , i n d i v i d u a l s may establish a private practice i n s o c i a l work without being registered. Furthermore, the BCASW i t s e l f , while i n d i c a t i n g that a B.S.W. or M.S.W. degree are satisfactory credentials for r e g i s t r a t i o n , also registers individuals with no professional t r a i n i n g i n s o c i a l work but who have had one year of f u l l t i m e employment i n a s o c i a l work position. As a r e s u l t of t h i s c i r c u m s t a n c e , a second o r g a n i z a t i o n representing s o c i a l workers, the Associated Professional Social Workers of B r i t i s h Columbia (APSWBC), has formed an interest group to lobby for a l e g i s l a t i v e act which would t r u l y give s o c i a l workers control of t i t l e and require professional t r a i n i n g for the designation of s o c i a l worker. The APSWBC i s incorporated under the Society Act (R.S.B.C. 1979, c 390) and i t s stated objectives include the recognition and maintenance \"as a minimal acceptable standard of education for s o c i a l work practice, the completion of a university degree i n s o c i a l work [and the] l i c e n s i n g of professional s o c i a l workers for the protection of the profession and the p u b l i c \" 1 Although the APSWBC has no s t a t u t o r y powers, i t has established a regi s t e r , a code of ethics, and d i s c i p l i n a r y procedures (APSWBC, 1981). The requirement for membership i s presentation of credentials i n d i c a t i n g the applicant holds a B.S.W. or M.S.W. degree. The APSWBC has proposed the Social Workers Act, which would establish a Board of Social Work Examiners wi t h the power t o r e g i s t e r s o c i a l workers, to e s t a b l i s h a code of ethics, and to d i s c i p l i n e members (Social Workers Act (proposed), s.7(7), s.7(9), and s.12)). The act would control the t i t l e of \"Social Worker\" and would establish four specialty t i t l e s , \"Social Worker,\" \"Licensed Social Worker,\" \"Licensed 67 C l i n i c a l Social Worker,\" and \"Licensed Social Work Specialist\", (s.5 and s.8), each requiring successively higher q u a l i f i c a t i o n s i n t r a i n i n g and experience. For example, requirements for r e g i s t r a t i o n as a Social Worker would be a B.S.W. degree, s a t i s f a c t o r y performance on an examination set by the Board, and employment under the supervision of a Licensed Social Worker, while for r e g i s t r a t i o n as a Licensed Social Work Sp e c i a l i s t , the application would need an M.S.W. or D.S.W. degree, f i v e years post-graduate experience, and to pass the examination. The act would provide a d e f i n i t i o n of practice (s.5) but would not control practice (s.19); however, i t would specify that individuals seeking to establish a private practice i n s o c i a l work must have the designation of Licensed Social Work Sp e c i a l i s t (s.15(1)). The act would give the Board of Examiners the power to fine individuals who used any of the t i t l e s i l l e g a l l y (s.18(1)) and to f i n e individuals who established a private practice i l l e g a l l y (s.18(3)). (For statutory references, please refer to Appendix B.4.a, Appendix B.4.b, and Appendix B.4.c.) 5.2 PROFESSIONAL PRACTICE PRIVILEGES Psychiatry In B r i t i s h Columbia, p s y c h i a t r i s t s p r a c t i c e as independent pr a c t i t i o n e r s , are independently l e g a l l y l i a b l e , and are f r e q u e n t l y q u a l i f i e d by the courts as expert witnesses. As medical p r a c t i t i o n e r s , p s y c h i a t r i s t s are among the professions reimbursed on a fee-for-service basis through the p r o v i n c i a l medical insurance plan as well as being paid through sessional and sal a r i e d funding arrangements. Through f o r m a l s t a t u t o r y r e c o g n i t i o n , again i n t h e i r r o l e as medical p r a c t i t i o n e r s , p s y c h i a t r i s t s enjoy a number of p r a c t i c e p r i v i l e g e s . P s y c h i a t r i s t s have been granted h o s p i t a l admission and discharge 68 p r i v i l e g e s (Hospital Act Regulations, B.C. Reg. 289\/73) and prescribing p r i v i l e g e s (Medical Practitioners Act). Psychiatrists have also been granted the power to diagnose and treat mental disorders (Medical Practitioners Act), to commit individuals to a mental hospital (Mental Health Act, R.S.B.C. 1979, c 256), and the power to declare individuals mentally incompetent (Patients Property Act, R.S.B.C. 1979, c. 313). As medical p r a c t i t i o n e r s , p s y c h i a t r i s t s are included with dentists i n the Infants Act (R.S.B.C. 1979, c 196) requirements for parental consent to the treatment of a minor. In addition, the evidence of psy c h i a t r i s t s i s s p e c i f i c a l l y recognized i n statutes dealing with fitness to drive (Motor Vehicle Act, R.S.B.C. 1979, c- 288), fitness to stand t r i a l and criminal insanity (Criminal Code Act, R.S.C. 1970, c.34), and fit n e s s to stand t r i a l and disposition of juvenile offenders (Young Offenders Act, S.C. 1980-81-82-83, c 110). As w e l l , i n B r i t i s h Columbia, ps y c h i a t r i s t s are charged through the Forensic Psychiatry Act (R.S.B.C. 1979, c 139) with the assessment and care of the criminally insane. Psychology In B r i t i s h Columbia, p s y c h o l o g i s t s p r a c t i c e as independent pr a c t i t i o n e r s , are independently l e g a l l y l i a b l e , and are f r e q u e n t l y q u a l i f i e d by the courts as expert witnesses. Through formal statutory recognition, psychologists have been granted the power to diagnose and treat mental disorders (Psychologists Act). In addition, the evidence of psychologists i s s p e c i f i c a l l y recognized i n statutes dealing with fi t n e s s to drive (Motor Vehicle Act) and fitness to stand t r i a l and disposition of juvenile offenders (Young Offenders Act). Psychologists are recognized i n polic y decisions requiring psychometric test r e s u l t s , such as authorization of e l i g i b i l i t y for special education programs TABLE VII Practice Privileges for Mental Health Professions i n B r i t i s h Columbia PRACTICE PRIVILEGE PROFESSION Psychiatry Psychology Ps y c h i a t r i c Nursing S o c i a l Work General Recognition Independent Practice of Profession Yes Yes Yes Yes Independently Legally Liable Yes Yes Yes Yes Expert Witness Status Yes Yes Yes Yes Payment Status Third Party Payment Government Yes No Ho No Private C a r r i e r s Yes Yes No No Sessional Payment Yes Yes No No Salaried Payment Yes Yes Yes Yes Foraal Statutory Recognition vc Diagnosis and Treatment Psychologists Act of Mental Disorders T R . S . B . C . 1 9 7 9 , c. 3 4 2 ) Medical Practitioners Act (R.S.B.C. 1 9 7 9 , c. 2 5 4 ) Yes Yes No No Care of the Criminally Insane Forensic Psychiatry Act (R.S.B.C. 1 9 7 9 , c. 1 3 9 ) Yes No No No Treatment of Minors Infants Act Parental Consent (R.S.B.C. 1 9 7 9 , c. 1 9 6 ) Required Yes No No No Hospital Admission and Discharge Privileges Hospital Act (R.S.B.C. 1 9 7 9 , c. 1 7 6 ) Yes No No No Prescribing P r i v i l e g e s Medical Practitioners Act (R.S.B.C. 1 9 7 9 , c. 2 5 4 ) Yes No No No Commitment Mental Health Act (R.S.B.C. 1 9 7 9 c. 2 5 6 ) Yes No No No Incompetency Patients Property Act (R.S.B.C. 1 9 7 9 , c. 3 1 3 ) Yes No No No Evidence Cited Fitness to Drive Motor Vehicle Act (R.S.B.C. 1 9 7 9 , c. 2 8 8 ) Yes Yes No No Fitness to Stand Criminal Code Act Yes No No No T r i a l (R.S.C. 1 9 7 0 , c. 3 4 ) Yes(proposed) Yes(proposed) Yes(proposed) Criminal Insanity Criminal Code Act Yes No No No (R.S.C. 1 9 7 0 , c. 3 4 ) Yes(proposed Yes(proposed) Yes(proposed) Fitness to Stand Young Offenders Act T r i a l and Disposition (S.C. 1 9 8 0 - 8 1 - 8 2 - 8 3 , c. 1 1 0 ) Yes Yes No No TABLE VII (Continued) P r a c t i c e P r i v i l e g e s f o r Mental Health P r o f e s s i o n s i n B r i t i s h Columbia Informal Statutory Recognition Statutory Responsibilities Adoption Adoption Act (R.S.B.C. 1979, c. 4) NO NO No Yes P a t e r n i t y C h i l d P a t e r n i t y and Determination Support Act (R.S.B.C. 1979, c. 49) No NO No Yes L i c e n s i n g of Mental Community Care F a c i l i t y Health Boarding Homes Act (R.S.B.C. 1979, c. 57) NO NO NO Yes C h i l d P r o t e c t i o n Apprehension Family and C h i l d S ervices Guardianship Act (R.S.B.C. 1979, c. 119) NO NO NO Yes Disputed Custody Family R e l a t i o n s Act (R.S.B.C. 1979, c. 121) NO NO NO Yes Breach of Order i n For e n s i c P s y c h i a t r y Act Cou n c i l P a t i e n t s (R.S.B.C. 1979, c. 139) NO No Yes Yes E l i g i b i l i t y f o r Guaranteed A v a i l a b l e Income Comfort Allowance Need Act (R.S.B.C. 1979, c 158) NO NO No Yes Commitment ( T h i r d Mental Health Act Signatory) (R.S.B.C. 1979, c. 313) NO NO Yes Yes Incompetence (regard- P a t i e n t s Property Act ing Managing A f f a i r s ) (R.S.B.C. 1979, C 313) Yes NO NO Yes Guardian i n Court Young Offenders Act Proceedings (S.C. 1980-81-82-83, c. 110) NO No NO Yes Policy Responsibilities E l i g i b i l i t y Decisions \u2022 S o c i a l Welfare Programs f o r the Mentally Retarded Yes Yes NO Yes S p e c i a l Education Programs f o r the Learning Disabled and Mentally Retarded No Yes No No Placement i n Mental Health or Psycho-G e r i a t r i c Boarding Home No No NO Yes Administration Supervisors of C.C.T. and C.M.H.C. Outpatient Treatment F a c i l i t i e s Yes Yes Yes Yes 71 f o r the learning disabled and mentally retarded and e l i g i b i l i t y for s o c i a l welfare programs for the mentally retarded. Psychiatric Nursing In B r i t i s h Columbia\/ psychiatric nurses are independently l e g a l l y l i a b l e and have been c a l l e d by the courts as expert witnesses. Although as nurses\/ psychiatric nurses perform some of th e i r duties i n response to the written and verbal orders of p s y c h i a t r i s t s , psychiatric nurses are increasingly coming to be considered independent p r a c t i t i o n e r s . In B r i t i s h Columbia, when psychiatric nurses are employed i n Community Care Teams or Community Mental Health Centres, they carry t h e i r own case loads and are not under s t a t u t o r y o b l i g a t i o n to consult with a p s y c h i a t r i s t (Stewart, 1986). T y p i c a l l y , i n t h e i r employment situations, team members work i n consultation with one another, with the p s y c h i a t r i s t p r e s c r i b i n g medication and the p s y c h i a t r i c nurse administering i n j e c t i o n s , monitoring medication, f o r m u l a t i n g a care p l a n , and providing psychotherapeutic intervention (e.g. l i f e s k i l l s t r a i n i n g , supportive counselling, psychotherapy). In CCT's and CMHC's, psyc h i a t r i s t s are not employed as c l i n i c a l supervisors and only rarely as administrative supervisors; however, there are a number of instances i n which psychiatric nurses act as administrative supervisors. With regard to leg a l l i a b i l i t y , psychiatric nurses are more frequently being h e l d independently l e g a l l y l i a b l e f o r t h e i r practice performance. Previously, when psychiatric nurses were almost exclusively employed i n large i n s t i t u t i o n s , p l a i n t i f f s usually sued the i n s t i t u t i o n and perhaps the attending physician. However, as the aspirations of nurses for independent practice have grown, there has been a corresponding growth i n s u i t s against nurses. The RPNABC requires members to purchase p r o f e s s i o n a l l i a b i l i t y insurance through t h e i r r e g i s t r a t i o n fees. Informal statutory recognition has been granted to psychiatric nurses i n the power to rehospitalize patients released from the forensic hospital for v i o l a t i o n s of release conditions (Forensic Psychiatry Act) and to act as the t h i r d signatory when no r e l a t i v e i s available for commitment orders (Mental Health Act)\u2022 Social Work In B r i t i s h Columbia, s o c i a l workers p r a c t i c e as independent pr a c t i t i o n e r s , are independently l e g a l l y l i a b l e , and are f r e q u e n t l y q u a l i f i e d as expert witnesses. Informal statutory recognition has been granted to s o c i a l workers across a wide range of statutes. S o c i a l workers have been granted the power to enforce the laws dealing with adoption (Adoption Act, R.S.B.C. 1979, c.4), c h i l d protection (Family & Child Services Act, R.S.B.C. 1979, c 119), and li c e n s i n g of mental health and psychogeriatric boarding homes (Community Care F a c i l i t y Act, R.S.B.C. 1979, c- 57). As w e l l , s o c i a l workers have been given r e s p o n s i b i l i t i e s under the statutes dealing with paternity determination (Child Paternity & Support Act, R.S.B.C. 1979, c 49), c h i l d custody disputes (Family Relations Act, R.S.B.C. 1979, c 121), and appearing as guardian i n court proceedings for children-in-care charged as juvenile offenders (Young Offenders Act.) As i n the case of psychiatric nurses, s o c i a l workers have been granted the power to r e h o s p i t a l i z e f o r e n s i c p a t i e n t s (Forensic Psychiatry Act) and to act as the t h i r d signatory on commitment orders (Mental Health Act). Social Workers have also been granted the power to determine e l i g i b i l i t y f o r comfort allowances (Guaranteed Available Income Need Act, R.S.B.C. 1979, c 158) and to act as the second 73 signatory i n determination of mental incompetency i n f i n a n c i a l matters (Patients Property Act)\u2022 Social Workers are recognized i n a number of policy decisions, for example, the authorization of e l i g i b i l i t y for placement i n mental health or psychogeriatric boarding homes and e l i g i b i l i t y for s o c i a l welfare programs for the mentally retarded, and are also the d i s c i p l i n e most fr e q u e n t l y designated as a d m i n i s t r a t i v e supervisors for CMHC's i n B r i t i s h Columbia. 5.3 LICENSURE STANDARDS AND PRACTICE PRIVILEGES COMPARED With regard to professional licensing standards for the four core mental health professions i n B r i t i s h Columbia, licensure l e g i s l a t i o n applies only to medical practitioners (and hence to p s y c h i a t r i s t s ) , while r e g i s t r a t i o n l e g i s l a t i o n applies to psychologists, psychiatric nurses, and s o c i a l workers. Thus, i n theory, psychiatry has the power to control practice while the other professions do not. However, as we have seen i n the discussion of professional t r a i n i n g standards, a l l four p r o f e s s i o n a l d i s c i p l i n e s r e c e i v e t r a i n i n g i n assessment and psychotherapy with mentally disordered c l i e n t s . In examining the relationship between professional t r a i n i n g standards, on the one hand, and professional licensure standards and practice p r i v i l e g e s , on the other, we see that psychiatry does not maintain the same degree of monopoly over practice as other medical p r a c t i t i o n e r s . For example, when we compare the Medical Practitioners Act and the Psychologists Act, we f i n d that both psychiatry and psychology have been authorized to diagnose and treat mental disorders: 74 Medical Practitioners Act s.72(2) For the purposes of and without r e s t r i c t i n g the g e n e r a l i t y of subsection (1)\/ a person p r a c t i c e s medicine who (b) diagnoses, or offers to diagnose, a human disease, ailment, deformity, defect or inj u r y , or who examines or advises on, or offers to examine or advise on, the physical or mental condition of a person. s.73 For the purposes of section 72, a person does not practice or offer to practice medicine who (i ) practices psychology while registered under the Psychologists Act. Psychologists Act s. 1 In t h i s Act ...\"practice of psychology includes\" (b) the a p p l i c a t i o n of methods and procedures of i n t e r v i e w i n g , c o u n s e l l i n g , psychotherapy, behavior therapy, behavior modification, hypnosis, research; or (c) the construction, administration, and interpretation of tests of mental a b i l i t i e s , a p t i t u d e s , i n t e r e s t s , o p i n i o n s , a t t i t u d e s , emotions, personality character-i s t i c s , motivations and psychophysiological character-i s t i c s and the assessment or diagnosis of behavioral, emotional and mental disorder f o r a fee or reward, monetary or otherwise. s.15 Nothing i n t h i s Act e n t i t l e s a person to practice medicine within the meaning of section 72 of the Medical Practitioners Act, but, notwithstanding that section, a r e g i s t e r e d psychologist i s c e r t i f i e d to carry on the practice of psychology without supervision by a medical pra c t i t i o n e r . Thus, by statute, neither profession has exclusive control over treatment or diagnosis, nor can e i t h e r p r o f e s s i o n be r e q u i r e d t o practice under the supervision of the other. S i m i l a r l y , through policy i n i t i a t i v e s , both s o c i a l workers and p s y c h i a t r i c nurses have been authorized to provide assessments of patients; i n a memorandum to CMHC directors, the Executive Director of Mental Health Services for B r i t i s h Columbia issued the following d i r e c t i v e regarding assessment practice: \"Re: DSM-III C l a s s i f i c a t i o n : As you know, we have introduced the DSM-III c l a s s i f i c a t i o n system A p r i l 1, 1985. When the new Management Information System for Mental Health Centres i s introduced, we w i l l r e q u i r e that the DSM-III c l a s s i f i c a t i o n of each c l i e n t be recorded to provide data on the types of problems our 75 service i s dealing with. A question has arisen about non-licensed p r o f e s s i o n a l s making DSM-III c l a s s i f i -cations and whether t h i s may be a v i o l a t i o n of the Medical P r a c t i t i o n e r s Act. We have received l e g a l advice that the use of DSM-III as a c l a s s i f i c a t i o n system does not v i o l a t e the Medical Practitioners Act since that Act i s concerned with l i m i t i n g diagnosis and treatment to medical practitioners\/ or other licensed p r a c t i t i o n e r s . I t i s important to stress that i t i s a DSM-III c l a s s i f i c a t i o n being made by non-licensed professionals rather than a diagnosis.\" 2 Likewise, p r o v i n c i a l government job descriptions for psychologists, psychiatric nurses and s o c i a l workers i n CMHC's indicate that a l l three p r o f e s s i o n s are e x p e c t e d t o p r o v i d e b o t h a s s e s s m e n t and psychotherapeutic intervention i n the course of th e i r employment: \" L i c e n s e d P s y c h o l o g i s t 3\/4: As p a r t of a mul t i d i s c i p l i n a r y team, provide assessment, treatment, and c o n s u l t a t i o n s e r v i c e s to indi v i d u a l s , f a m i l i e s , groups and agencies; provide psychological t e s t i n g to mental health c l i n i c s as required.\" 3 \"Community Nurse 3: Under general direction of team lea d e r , to f u n c t i o n independently with p s y c h i a t r i c consultation available, as primary or co-therapist on mu 11 i - d i s c i p 1 i nary team t h a t p r o v i d e s c r i s i s i n t e r v e n t i o n and\/or l o n g e r term t r e a t m e n t t o b e h a v i o r a l l y or e m o t i o n a l l y d i s t u r b e d c h i l d r e n , adolescents and th e i r f a m i l i e s ; nursing assessments, i d e n t i f y i n g and implementing treatment plans; evaluating responses to th e r a p e u t i c regimes; p a r t i c i p a t i n g i n various treatment modalities, discharge planning and follow up. 1 , 4 \"Psychiatric Social Worker 4: Provide a wide range of services to catchment area; assess resources\/needs, d e t e r m i n e p r o g r a m p r i o r i t i e s ; p a r t i c i p a t e i n developing\/implementing programs; provide s e r v i c e s -c r i s i s i n t e r v e n t i o n , assessments, case finding for serious i l l n e s s , treatment planning and therapy f o r i n d i v i d u a l s , f a m i l i e s , groups u t i l i z i n g modalities requiring advanced s k i l l s . \" 5 Thus, while psychiatry i s regulated under a lic e n s i n g act and while the s o c i a l work r e g i s t r a t i o n a c t i s e s s e n t i a l l y m e a n i n g l e s s , n e v e r t h e l e s s , i n B r i t i s h Columbia a l l four core mental he a l t h 76 professions are authorized to practice assessment and psychotherapeutic i n t e r v e n t i o n with the mentally d i s o r d e r e d and t o f u n c t i o n as independent, l e g a l l y l i a b l e p r a c t i t i o n e r s . Although professionals from the various d i s c i p l i n e s may function as administrative supervisors, they do not function as c l i n i c a l supervisors; rather, the professions are accountable to t h e i r r e g i s t r a t i o n bodies f o r t h e i r standards of practice. With r e g a r d t o p r a c t i c e p r i v i l e g e s , i n B r i t i s h Columbia, psych i a t r i s t s have been given the greatest degree of formal statutory recognition. Psychiatry i s the only d i s c i p l i n e of the four core mental h e a l t h p r o f e s s i o n s which has been granted h o s p i t a l p r i v i l e g e s , prescribing p r i v i l e g e s , and the power to make declarations of commitment and competency. Social workers and psychiatric nurses have been given i n f o r m a l r e c o g n i t i o n i n commitment proceedings i n that while two signatures must be those of medical p r a c t i t i o n e r s , the t h i r d signature, usually that of a r e l a t i v e , i s i n practice provided by these l a t t e r two d i s c i p l i n e s i f no r e l a t i v e i s available- As w e l l , i n incompetency proceedings dealing solely with the management of f i n a n c i a l a f f a i r s , p o l i c y directives allow one of the two signatories to be a s o c i a l worker rather than a medical p r a c t i t i o n e r . P s y c h i a t r i s t s also have the greatest degree of recognition and f l e x i b i l i t y i n terms of funding arrangements. With recognition under the p r o v i n c i a l medical insurance plan, p s y c h i a t r i s t s have by far the greatest opportunity to engage i n fee-for-service private practice as w e l l as the option to work i n s e s s i o n a l or s a l a r i e d situations. Information from the Medical Services Plan of B r i t i s h Columbia for the year 1980-81 indicated that 71 percent of payments to p s y c h i a t r i s t s were fee-for-service, 15 percent sessional, and 14 percent salaried. 77 Psychologists are reimbursed through both sessional and s a l a r i e d funding arrangements with the p r o v i n c i a l government; they are not i n c l u d e d i n f e e - f o r - s e r v i c e funding under the p r o v i n c i a l medical insurance plan. There are fewer psychologists than p s y c h i a t r i s t s i n p r i v a t e p r a c t i c e and f ee-f or-service funding arrangements are more varied. A survey completed by the B r i t i s h Columbia P s y c h o l o g i c a l Association (1981) found that 51.9 percent of psychologists were i n f u l l t i m e s a l a r i e d positions and of those i n p r i v a t e p r a c t i c e , 7.7 percent were i n practice f u l l t i m e , 6.2 percent spent 25-75 percent of t h e i r time i n practice, and 26.4 percent spent less than 25 percent of t h e i r time i n p r i v a t e p r a c t i c e . In addition to direct fees from c l i e n t s , psychologists i n private practice have fee-for-service funding arrangements with Canada Employment and Immigration, union benefit programs, employee assistance programs, the M i n i s t r i e s of Health, Social Services, and the Attorney General, and v i c t i m compensation programs. Social workers and psychiatric nurses are u s u a l l y employed i n s a l a r i e d situations; neither professional group has fee-for-service or sessional funding arrangements at the present time. Some s o c i a l workers and psychiatric nurses engage i n private practice with c l i e n t s paying d i r e c t l y . The private practice s i t u a t i o n i s s i m i l a r for psychiatric nurses, with the added circumstance that psychiatric nurses often prefer to i d e n t i f y themselves as \"counsellors\" rather than as nurses. With regard to expert witness status, p s y c h i a t r i s t s have once again been given the greatest degree of formal statutory recognition. However the court has the power to recognize any of the four core mental health professions as expert witnesses under the Evidence Act (R.S.B.C. 1979, c 116). The evidence of p s y c h i a t r i s t s and psychologists i s formally recognized under the Motor Vehicle Act and the Young Offenders Act. As 78 w e l l , p s y c h i a t r i s t s are formally recognized under the Criminal Code Act, i n proceedings d e a l i n g w i t h f i t n e s s to stand t r i a l and c r i m i n a l i n s a n i t y . The courts have been i n the practice for some time of recognizing the evidence of psychologists as well i n these l a t t e r two categories. Hence, i n a White Paper currently being cir c u l a t e d by the federal government (Minister of Justice and Attorney General of Canada, 1986), the proposal has been made to amend the Criminal Code Act deleting s p e c i f i c reference to the evidence of medical practitioners and l e a v i n g d i s c r e t i o n completely to the bench i n q u a l i f y i n g expert witnesses i n matters of f i t n e s s and insanity. The amendment would have the e f f e c t of l e g i t i m i z i n g the evidence presently being provided by psychologists and would suggest greater l a t i t u d e for the q u a l i f i c a t i o n of s o c i a l workers and psychiatric nurses as expert witnesses as well. With regard to informal statutory recognition, i t would appear that s o c i a l workers have been granted the greatest recognition. Under a wide range of statutes, s o c i a l workers have been charged with the enforcement of l e g i s l a t i o n or with the authorization of e l i g i b i l i t y for programs established through l e g i s l a t i o n . Many of the decisions which s o c i a l workers are c a l l e d upon to make have profound effects on the l i v e s of ind i v i d u a l s , most obviously i n the area of c h i l d p r o t e c t i o n , where s o c i a l workers have been granted the power to investigate complaints of c h i l d neglect and abuse, to apprehend children, to serve as guardians, and to act as expert witnesses i n proceedings dealing with temporary and permanent wardship. I t i s somewhat s t a r t l i n g , then, given the significance of the roles s o c i a l workers perform, that the profession of s o c i a l work i s so loosely regulated. To summarize, i n reviewing the statutes and p o l i c i e s which document professional licensure standards and practice p r i v i l e g e s , i t appears 79 that while there are many functions which are unique to each of the four core mental health professions, there are also a number of functions which overlap. The p r i n c i p a l point of overlap which i s of concern to us i n the present context i s the recognition of a l l four d i s c i p l i n e s as p r o v i d e r s of psychotherapy s e r v i c e s and, most p a r t i c u l a r l y , the recognition of both p s y c h i a t r i s t s and psychologists as empowered by statute to diagnose and treat mental disorders. 5.4 POTENTIAL PRACTICE PRIVILEGES FOR PSYCHOLOGISTS As the present study places p a r t i c u l a r emphasis on a comparison of psychiatry and psychology i n i t s development of a manpower substitution model and i t s examination of the implications of the model for the cost of mental health service delivery, a more detailed discussion of the s i m i l a r i t i e s and differences i n the practice privileges for these two professions seems i n order. Table VII divides practice p r i v i l e g e s into three categories: general recognition, formal statutory recognition, and informal statutory recognition. With regard to i n f o r m a l s t a t u t o r y r e c o g n i t i o n , the practice p r i v i l e g e s l i s t e d i n Table VII do not appear to bear on simple s u b s t i t u t i o n i n p r i v a t e p r a c t i c e p s y c h i a t r i c s e r v i c e s as these p a r t i c u l a r professional functions occur mainly w i t h i n i n s t i t u t i o n a l settings. However, with regard to general recognition, a l l the practice p r i v i l e g e s l i s t e d i n Table VII do appear to bear on simple substitution. Psychiatrists and psychologists share the same practice p r i v i l e g e s of independent professional practice, independent le g a l l i a b i l i t y , expert witness status, t h i r d party payment by private c a r r i e r s , and sessional and s a l a r i e d payment arrangements with government. However, while p s y c h i a t r i s t s have made f e e - f o r - s e r v i c e funding agreements with 80 government\/ p s y c h o l o g i s t s have not. Although the p r o v i n c i a l psychologists' r e g i s t r a t i o n bodies have approached t h e i r r e s p e c t i v e governments with proposals (BCPA, 1986), no p r o v i n c i a l government has yet concluded a fee-for-service arrangement with psychologists. These proposals have presented the case for the f e a s i b i l i t y of government fee-for-service coverage and I w i l l refer to these arguments i n Chapter Ten, when the licensure and market r i g i d i t i e s which would need to be changed f o r implementation of simple s u b s t i t u t i o n f o r p r i v a t e p r a c t i c e psychiatry services are addressed. With regard to formal s t a t u t o r y r e c o g n i t i o n , there i s more disparity than i s the case for either informal statutory recognition or general r e c o g n i t i o n i n the degree to which the practice p r i v i l e g e s granted to the two professions bear on simple substitution p o s s i b i l i t i e s f o r p r i v a t e p r a c t i c e p s y c h i a t r y s e r v i c e s . P s y c h i a t r i s t s and psychologists share the same p r a c t i c e p r i v i l e g e s of diagnosis and treatment of mental disorders, requirement to report under statutes dealing with f i t n e s s to drive, and expert witness status regarding f i t n e s s to stand t r i a l , criminal insanity, and juvenile offenders. However, while p s y c h i a t r i s t s have been accorded formal s t a t u t o r y recognition i n the care of the criminally insane, the requirement of parental consent to treat a minor, hospital p r i v i l e g e s , p r e s c r i b i n g p r i v i l e g e s , and the power to commit and to declare incompetent, psychologists have not. Two of these practice p r i v i l e g e s do not appear to bear d i r e c t l y on s u b s t i t u t i o n i n p r i v a t e p r a c t i c e psychiatric services. The f i r s t , the care of the criminally insane, takes place i n an a p p r o p r i a t e l y designated agency which contracts services with psy c h i a t r i s t s and psychologists i n accordance with the status of other practice p r i v i l e g e s . The second, the requirement of parental consent to 81 treat a minor, constitutes a r e s t r i c t i o n rather than an enhancement of practice privileges and, i n any case, i s a practice observed, as a matter of p o l i c y , by non-medical as w e l l as medical h e a l t h p r a c t i t i o n e r s . The remaining four practice p r i v i l e g e s , i . e . , hospital p r i v i l e g e s , p r e s c r i b i n g p r i v i l e g e s , and the power to commit and to declare incompetent, do appear to bear on private practice. Of these, h o s p i t a l p r i v i l e g e s have been the p r i n c i p a l focus of attempts by p s y c h o l o g i s t s to extend formal s t a t u t o r y r e c o g n i t i o n . W h i l e psychologists have tended to perceive hospital p r i v i l e g e s as f a l l i n g within t h e i r competence and necessary to t h e i r professional practice, they have not, for the most part, perceived prescribing p r i v i l e g e s as within t h e i r expertise or as necessary to th e i r practice; therefore, they have pursued the former with vigour and persistence but have almost e n t i r e l y ignored the l a t t e r . With regard to the power to commit and to declare incompetent, these two practice p r i v i l e g e s appear to be less contentious and to flow more eas i l y and, sometimes, as a matter of course once the hurdle of hospital p r i v i l e g e s has been overcome. In discussing hospital p r i v i l e g e s , i t i s necessary to distinguish between c l i n i c a l and s t a f f p r i v i l e g e s . C l i n i c a l p r i v i l e g e s refer to a c t i v i t i e s such as admission, discharge, and the treatment of patients while s t a f f p r i v i l e g e s refer to membership on the medical s t a f f with the power to vote, hold o f f i c e , and serve on committees. Arnett, Martin, S t r e i n e r , and Goodman ( 1987) have recently reviewed the status of hospital p r i v i l e g e s for psychologists i n Canada. They report that 10 percent of Canadian Psychological Association members work as f u l l - t i m e employees i n hospitals, a figure s i m i l a r to U.S. s t a t i s t i c s . With regard to s t a f f p r i v i l e g e s , the authors found that only two percent of the psychologists were f u l l voting members of th e i r hospital medical 82 sta f f associations. With regard to c l i n i c a l p r i v i l e g e s , the authors found that 57 percent of the hospitals did not require a physician's r e f e r r a l for psychological assessment or treatment to be conducted but the authors were not aware of any Canadian h o s p i t a l s g r a n t i n g independent admitting and discharge p r i v i l e g e s to psychologists. Thus, i t i s apparent that psychologists i n Canada function i n hospitals with r e s t r i c t e d treatment p r i v i l e g e s , very l i m i t e d s t a f f p r i v i l e g e s , and no admission or discharge p r i v i l e g e s . In the United States, Dorken, Webb, and Zaro (1982), i n a survey conducted i n 1980, found that for psychologists p r a c t i c i n g i n hospitals 25 percent had formal medical s t a f f p r i v i l e g e s ( f u l l , associate, consulting, or courtesy membership) and 20 percent had formal c l i n i c a l p r i v i l e g e s ; for psychologists with c l i n i c a l p r i v i l e g e s , approximately 50 percent practiced independently of physician r e f e r r a l but v i r t u a l l y none had independent admission or discharge p r i v i l e g e s . However, as an examination of statutes and hospital and accreditation standards and of recent developments both i n Canada and the United States shows, t h i s r e s t r i c t i o n of hospital p r i v i l e g e s to medical practitioners appears to be more the r e s u l t of convention than of a lack of f e a s i b i l i t y i n extending hospital p r i v i l e g e s to non-medical pr a c t i t i o n e r s . In the Canadian context, we might f i r s t note that Arnett e_t a l . comment that the standards for accreditation of health care f a c i l i t i e s set f o r t h by the Canadian Council on Hospital Accreditation (1985) allow for s t a f f p r i v i l e g e s i n a special membership category for non-physician d o c t o r a l s c i e n t i s t s and others who qua l i f y for c l i n i c a l p r i v i l e g e s . Furthermore, i n B r i t i s h Columbia, the Hospital Act Regulations permit the granting of treatment p r i v i l e g e s to non-medical practitioners under Section 4(3): 83 \"The Board of a hospital may, subject to the approval of the Minister, provide...for service or treatment to be rendered to a patient by persons who are not members of the College of Physicians and Surgeons of B r i t i s h Columbia, provided that the re s p o n s i b i l i t y for admitting the patient to the hospital and discharging him therefrom and for the medical care of the patient while he remains i n hospital rests with the member of the medical s t a f f of the hospital who i s attending the said patient.\" A c c o r d i n g l y , the C h i r o p r a c t i c Association of B r i t i s h Columbia recently made application to the B.C Hospital Association for hospital treatment p r i v i l e g e s (Nixdorf, 1986). However, the BCHA has so far chosen to r e s i s t the chiropractors' request by ignoring Section 4(3) i n favour of a s t r i c t interpretation of Section 4(1): \"... no person may attend or treat patients i n a h o s p i t a l , or i n any way a v a i l himself of the f a c i l i t i e s for medical practice i n a hospital unless he i s a member i n good standing of the College of Physicians and Surgeons of B r i t i s h Columbia, who holds a v a l i d permit from the board to practice medicine i n the hospital and who has been appointed to the medical s t a f f of that h o s p i t a l . \" A t h i r d i n t e r e s t i n g circumstance has occurred i n Alberta, where the Mental Health Act (R.S.A. 1972, c.118) formerly permitted powers of admission, commitment, and declaration of incompetency to licensed physicians and registered therapists (s.29, s.25, & s.35). Those e l i g i b l e to become registered therapists were psychologists, registered nurses, psychiatric nurses, and s o c i a l workers who had been duly enumerated by t h e i r r e g i s t r a t i o n bodies (s.6). However, because some of these professions did not have t h e i r i n d i v i d u a l r e g i s t r a t i o n acts i n place, these powers were reserved i n practice to physicians; i n 1979, the r e s t r i c t i o n was formalized when the Mental Health Act. (R.S.A. 1979, c.118) was amended and the reference to registered therapists was struck out (Wardell, 1986). In the United States, where non-medical practitioners have made considerably greater inroads into the status quo, psychologists have 84 pursued the granting of hospital p r i v i l e g e s through both l i t i g a t i o n and l e g i s l a t i o n . State psychological associations launched a s e r i e s of a n t i - t r u s t s u i t s agains.t the J o i n t Commission on Accreditation of Hospitals (JCAH), a private, nonprofit corporation whose r e s p o n s i b i l i t y i s the establishment and monitoring of hospital accreditation standards. At the commencement of the l i t i g a t i o n , JCAH standards did not permit psychologists to practice independently i n hospitals. The JCAH Board of Governors i s comprised of one representative from the American Dental Association, one public member, and 20 representatives from the American College of Surgeons, American College of Physicians, American Hospital Association, and American Medical Association (Tanney, 1983). Tanney notes that among the evidence c i t e d by the p e t i t i o n i n g psychologists was a study completed by Dorken (1983), analyzing the u t i l i z a t i o n data for inpatient psychiatric care under the insurance program for U.S. federal employees. For the year 1980, Dorken found that only 3.3 percent of the inpatient services provided by p s y c h i a t r i s t s were for medical services. The remaining 96.7 percent of a l l inpatient services could have been and were provided by either a p s y c h i a t r i s t or a psychologist within t h e i r scope of practice. The courts and the Federal Trade Commission agreed with the psychologists' argument that the denial of hospital p r i v i l e g e s to duly enumerated he a l t h care providers who met the standard for hospital p r a c t i c e c o n s t i t u t e d a h o r i z o n t a l boycott by p h y s i c i a n s (Bailey, 1983). As a r e s u l t , the JCAH backed away from i t s e a r l i e r refusal to grant hospital p r i v i l e g e s to psychologists and modified i t s standards to permit psychologists to practice independently i n hospitals i n those states having statutes guaranteeing t h i s right to practice. State psychological associations then pressed for the passage of t h i s e nabling l e g i s l a t i o n and i n a recent review of t h e i r progress, 85 Psychotherapy Finances ( 1985) reported that 24 j u r i s d i c t i o n s had h o s p i t a l l i c e n s u r e codes which permitted psychologists to act as independent service providers i n hospital settings. The D i s t r i c t of Columbia (Health-Care and Community Residence F a c i l i t y , Hospice\/ and Home Care Licensure Act, D.C. Law 5-48, 30 D.C.R. 5778) provides a useful example of the form and scope of t h i s l e g i s l a t i o n . \"Section 8(c) No p r o v i s i o n of D i s t r i c t of Columbia Law . . . s h a l l p r o h i b i t q u a l i f i e d nurse a n e s t h e t i s t s , nurse midwives, nurse p r a c t i t i o n e r s , p o d i a t r i s t s , or psychologists as a c l a s s from being accorded c l i n i c a l p r i v i l e g e s and appointed to a l l categories of s t a f f membership at those f a c i l i t i e s and agencies that o f f e r the type of service delivered by members of these classes and t h e i r p h y s i c i a n competitors. Notwithstanding any provision of law to the contrary, c l i n i c a l p r i v i l e g e s that may be accorded t o psychologists include, but are not li m i t e d to, the following: admission, examination, c e r t i f i c a t i o n of mental i l l n e s s , treatment and treatment plan authorization, and discharge.\". Thus, i t appears that i n a number of j u r i s d i c t i o n s i n the United S t a t e s , p s y c h o l o g i s t s have been granted a l l the formal statutory practice p r i v i l e g e s relevant to private practice substitution with the exception of prescribing p r i v i l e g e s . And, as we s h a l l see i n Chapter Seven, a review of the l i t e r a t u r e comparing the r e l a t i v e effectiveness of psychotherapy and pharmacotherapy indicates that a considerable proportion of the mental disorders seen by psy c h i a t r i s t s i n p r i v a t e practice settings can be treated e f f e c t i v e l y with psychotherapy alone. As with the lack of fee-for-service funding, I w i l l explore i n Chapter Ten whether the lack of hospital p r i v i l e g e s for psychologists i n Canada would constitute a barrier to private practice substitution. 86 CHAPTER SIX THE PROFESSIONS COMPARED AS PSYCHOTHERAPISTS If we grant that a l l four core mental health professions, by virtue of t h e i r t r a i n i n g and practice p r i v i l e g e s , provide psychotherapy services, then the next step i n considering the f e a s i b i l i t y of simple s u b s t i t u t i o n f o r private practice psychiatry services would appear to be to address the issue of the r e l a t i v e effectiveness of these psychotherapy services when delivered by different d i s c i p l i n e s . Chapter Six reviews the l i t e r a t u r e investigating s i m i l a r i t i e s and d i f f e r e n c e s i n the perceived c r e d i b i l i t y , c l i n i c a l a t t i t u d e s , c l i n i c a l effectiveness, and patterns of practice of the four professions i n an attempt to determine whether they deliver psychotherapy services of comparable quality within comparable time periods to comparable sets of presenting conditions. In presenting t h i s review, there i s the caveat that the studies which compare c l i n i c a l effectiveness (Section 6.3) have some methodological deficiencies. None of the studies has used a placebo group as a control condition. Hence, the evidence does not permit the stronger conclusion that the four core professions do not d i f f e r i n t h e i r effectiveness but rather only the somewhat weaker conclusion that there i s no evidence that the four professions do d i f f e r i n t h e i r effectiveness as psychotherapists. 6.1 PERCEIVED CREDIBILITY Perceived c r e d i b i l i t y can be examined from the perspective of the c l i e n t s ' views of the professionals or the professionals' views of each other. Taking the f i r s t p e r s p e c t i v e , G r a v i t z and Gerton (1977) interviewed 100 adults on the street i n Washington, D.C. and asked them 87 to rank an alphabetical l i s t i n g of ten mental health d i s c i p l i n e s for prestige. In descending order, subjects ranked the p r o f e s s i o n s as f o l l o w s : p s y c h i a t r i s t , psychoanalyst, p s y c h o l o g i s t , c o u n s e l l o r , p a s t o r a l c o u n s e l l o r , m a r r i a g e c o u n s e l l o r , p s y c h i a t r i c n u r s e , paraprofessional worker, psychiatric s o c i a l worker, and s o c i a l worker. In a second study, Trautt and Bloom (1982) asked 144 undergraduate students to rate a description of a mental health professional t i t l e d p s y c h i a t r i s t , counsellor, or psychologist, a l l with doctoral degrees, on various dimensions of att r a c t i o n and c r e d i b i l i t y . A s i g n i f i c a n t r e s u l t for t i t l e was found on willingness to recommend the therapist to a fr i e n d and results approaching significance were found for perceived safety and for willingness to seek treatment oneself. The pattern of these results was i d e n t i c a l ; the \"psychiatrist\" consistently was rated higher than the \"counsellor,\" who i n turn was rated higher than the \"p s y c h o l o g i s t . \" The p s y c h i a t r i s t d i f f e r e d s i g n i f i c a n t l y from the psychologist but did not d i f f e r s i g n i f i c a n t l y from the counsellor nor was t h e r e a s i g n i f i c a n t d i f f e r e n c e between the c o u n s e l l o r and psychologist. A l p e r i n and Benedict (1985) randomly assigned 180 u n i v e r s i t y students to rate either p s y c h i a t r i s t s , psychologists, or s o c i a l workers on an 85-adjective checklist and to indicate how l i k e l y they were to discuss seven problem areas with the person. On the adjective c h e c k l i s t , the largest difference occurred between perceptions of p s y c h i a t r i s t s and s o c i a l workers. The psych i a t r i s t s were perceived to be s i g n i f i c a n t l y more studious, c l e v e r , i n t e l l e c t u a l , a n a l y t i c , reserved, and d u l l than the s o c i a l workers, while the s o c i a l workers were perceived to be s i g n i f i c a n t l y more warm, c h e e r f u l , e n e r g e t i c , e n t h u s i a s t i c , s o c i a b l e , and a p p r e c i a t i v e than the p s y c h i a t r i s t s . Psychologists were perceived to be s i g n i f i c a n t l y more studious and 88 clever than the s o c i a l workers, while the s o c i a l workers were rated as s i g n i f i c a n t l y more c h e e r f u l and a c t i v e than the p s y c h o l o g i s t s . Psychologists were the professionals the subjects indicated they would be most l i k e l y to consult for help with the majority of th e i r problems. Taking the second perspective, Schindler, Berren, and Beigel (1981) sent a questionnaire to p s y c h i a t r i s t s , psychologists, s o c i a l workers, and nurses i n various mental health settings and asked them to evaluate how large a role p s y c h i a t r i s t s and psychologists played i n 11 everyday a c t i v i t i e s , how competent the two professions were to perform the a c t i v i t y , and how much r e s p o n s i b i l i t y each should have i n carrying out the a c t i v i t y . With regard to present r o l e , p s y c h i a t r i s t s rated themselves as having primary r e s p o n s i b i l i t y for a l l a c t i v i t i e s except te s t i n g , psychotherapy, and counselling. Other professionals supported these judgments, however, t h e i r ratings of r e s p o n s i b i l i t y assigned to p s y c h o l o g i s t s were g e n e r a l l y higher than the r a t i n g s t h a t the psy c h i a t r i s t s gave psychologists. Psychologists perceived p s y c h i a t r i s t s as being p r i m a r i l y responsible for program coordination, medication management, and t e s t i f y i n g as expert witnesses, while r e s e r v i n g to themselves r e s p o n s i b i l i t y for t e s t i n g , psychotherapy, and counselling. In the remaining c a t e g o r i e s of i n t a k e s c r e e n i n g , d i a g n o s t i c s , supervision and t r a i n i n g , and consultation and education, psychologists believed they had as much r e s p o n s i b i l i t y as p s y c h i a t r i s t s . In terms of competence, ps y c h i a t r i s t s rated themselves as being more competent than p s y c h o l o g i s t s to carry out eight of the 1 1 a c t i v i t i e s and perceived psychologists as more competent than themselves only i n conducting psychological testing. Psychologists saw themselves as more competent to carry out nine of the 11 a c t i v i t i e s , saw no difference i n t e s t i f y i n g as an expert witness, and viewed p s y c h i a t r i s t s 89 as more competent only i n the area of medication management. The other professionals saw no difference i n competency between the two for s i x of the a c t i v i t i e s \/ saw psychologists as more competent i n psychotherapy\/ counselling, and t e s t i n g , and p s y c h i a t r i s t s as more competent i n diagnostics and medication management-In considering i d e a l r o l e , p s y c h i a t r i s t s strongly believed t h a t they s h o u l d have r e s p o n s i b i l i t y f o r a l l the a c t i v i t i e s except psychotherapy, counselling, and testing. Psychologists believed that p s y c h i a t r i s t s should have primary r e s p o n s i b i l i t y only for medication management, that psychologists should take primary r e s p o n s i b i l i t y for psychotherapy, counselling, and te s t i n g , and that the two should share r e s p o n s i b i l i t y for the remaining a c t i v i t i e s . The other p r o f e s s i o n s generally agreed that psychologists should have equal r e s p o n s i b i l i t y for intake screening, psychotherapy, program coordination, supervision and t r a i n i n g , consultation and education, s t a f f i n g decisions, and t e s t i f y i n g as an expert witness. Newman, Carney, and Sharon (1978) investigated r e f e r r a l preferences among p s y c h i a t r i s t s , p s y c h o l o g i s t s , s o c i a l workers, and p a s t o r a l counsellors. Subjects were given two case h i s t o r i e s , one designed to represent neurosis and the other to represent psychosis, and asked subjects to indicate whether they would treat themselves or refer. If the choice was to r e f e r , they were asked to rank a l i s t of s i x professions i n order of preference. Psychiatrists were ranked f i r s t , followed by psychologists, s o c i a l workers, counsellors (pastoral and marriage), and layman-volunteer. 90 6.2 CLINICAL ATTITUDES Studies investigating the c l i n i c a l attitudes of the various mental health professions f i n d that differences do appear between professions as a function of th e o r e t i c a l orientation and perceived r o l e but the general role of \" c l i n i c i a n \" appears to override many other f a c t o r s , producing many s i m i l a r i t i e s . Abramowitz, Schwartz and Roback (1977) investigated the effects of professional d i s c i p l i n e and experience i n group psychotherapists 1 c l i n i c a l reactions. Subjects were 100 members of the American Group Psychotherapy Association and were p s y c h i a t r i s t s , p s y c h o l o g i s t s , or so c i a l workers. A detailed c l i n i c a l p r o f i l e of an outpatient i n group therapy was mailed to prospective subjects and they were asked to rate c l i n i c a l impression and therapy responses to the c l i e n t . The investigators found that more experienced t h e r a p i s t s , regardless of d i s c i p l i n e , tended to be more s t r i n g e n t i n e v a l u a t i n g l e v e l of adjustment, more pessimistic about prognosis, and more d i r e c t i v e i n therapeutic approach. Bernstein and Lecomte (1982) examined the effect of c l i e n t gender, therapist gender, therapist profession, and therapist l e v e l of t r a i n i n g on the d i a g n o s t i c , p r o g n o s t i c , and process expectancies held by therapists p r i o r to counselling with a s p e c i f i c c l i e n t . Subjects were a randomly selected sample which included 167 psychologists, 306 s o c i a l workers, 320 counsellors, 165 entering M.A. counselling\/psychology students, and 142 completing M.A. students. Subjects were sent a c l i e n t description t i t l e d either \"Marie\" or \"Thomas\" and asked to complete an inventory as i f they were going to see the c l i e n t i n treatment. Results indicated that c l i e n t gender produced no s i g n i f i c a n t d i f f e r e n c e s . However, therapist gender produced a s i g n i f i c a n t effect i n that male 91 t h e r a p i s t s expected to be more d i r e c t i v e than female therapists. Contrary to Abramowitz et a l . ( 1977), the a u t h o r s found t h a t p r o f e s s i o n a l t h e r a p i s t s expected to be less directive than student therapists but did r e p l i c a t e the tendency of experienced therapists to be more pessimistic about prognosis than less-experienced therapists. The three professions d i f f e r e d on only one dimension; c o u n s e l l o r s expected to be the most dir e c t i v e and s o c i a l workers the least with psychologists f a l l i n g between but not s i g n i f i c a n t l y different from the other two groups. The authors speculate that the differences i n expected directiveness between more- and less-experienced therapists and between professional d i s c i p l i n e s was a function of different t h e o r e t i c a l backgrounds i n t h e i r t r a i n i n g with the more directive being trained i n cognitive therapies and the less d i r e c t i v e i n client-centered therapies. They note that the student group was more l i k e l y to have been trained i n cognitive therapies than the older therapists as t h i s treatment method was i n vogue i n t r a i n i n g i n s t i t u t i o n s during that p a r t i c u l a r time period. S i m i l a r l y , H a r a r i and Hosey (1979) found differences between professional groups which could apparently be attributed to d i f f e r i n g t h e o r e t i c a l schools of therapy. Subjects were 9 p s y c h i a t r i s t s , 9 psychologists, and 9 s o c i a l workers at a community mental health centre i n the United States. Subjects were given three brief case h i s t o r i e s representing three different diagnostic categories (obsessive compulsive n e u r o s i s , anxiety neurosis, and h y s t e r i c a l neurosis) with causation attributed either to personal inadequacy, inadequate s o c i a l environment, or no cause. Subjects were asked to estimate the prognosis for the c l i e n t ' s recovery. Results i n d i c a t e d that p s y c h i a t r i s t s gave s i g n i f i c a n t l y better prognoses when the cause was personal inadequacy, 92 s o c i a l workers when the cause was inadequate s o c i a l environment, while psychologists showed a tendency toward better prognosis for personal inadequacy but not to the same degree as ps y c h i a t r i s t s . Psychiatrists also gave a s i g n i f i c a n t l y better prognosis to the h y s t e r i c a l neurosis c l i e n t s . The authors, as i n the previous study, speculate that because the p s y c h i a t r i s t s tended to be t r a i n e d i n psychodynamic therapy emphasizing intrapersonal variables rather than interpersonal variables, the psyc h i a t r i s t s tended to perceive the cases where personal inadequacy was the cause and h y s t e r i c a l neurosis was the diagnosis (hysterical neuroses are more frequently treated psychodynamically while anxiety neuroses are f r e q u e n t l y t r e a t e d behaviorally) as more amenable to treatment \u2022 Del Gaudio, Stein, Ansley, and Carpenter (1975) studied the degree to which the four core mental health professions perceived the community mental health movement as po s i t i v e . Subjects were 27 p s y c h i a t r i s t s , 14 psychologists, 12 s o c i a l workers, and 12 nurses i n a community mental health centre i n the United States. The investigators examined the effects of professional t r a i n i n g and socio-economic c l a s s (SES) on support for community mental health ideology (CMHI). Results indicated s i g n i f i c a n t e f f e c t s f o r both p r o f e s s i o n a l group and SES l e v e l . Psychologists and s o c i a l workers did not d i f f e r s i g n i f i c a n t l y from one another i n supporting CMHI but both groups were s i g n i f i c a n t l y more pos i t i v e than the other two groups. Although nurses were s i g n i f i c a n t l y l e s s p o s i t i v e than p s y c h o l o g i s t s and s o c i a l workers, they were s i g n i f i c a n t l y more pos i t i v e than p s y c h i a t r i s t s . Subjects from higher SES levels were found to be less p o s i t i v e i n th e i r support of CMHI. However, when the p r o f e s s i o n a l groups were compared ho l d i n g SES 93 constant\/ the d i f f e r e n c e s between the professional groups remained highly s i g n i f i c a n t . In the study by Newman, Carney, and Sharon (1978) referred to above, the subjects, which included 11 p s y c h i a t r i s t s , 17 psychologists, and 18 s o c i a l workers, were given two case h i s t o r i e s , one representing neurosis and one representing psychosis, and asked to indicate whether they would treat or refer. Results indicated that for the neurotic case a l l groups, about 80 percent, preferred to treat the c l i e n t but for the p s y c h o t i c case about 50 percent of psychologists and p s y c h i a t r i s t s preferred to refer, while 90 percent of s o c i a l workers preferred to treat the c l i e n t . 6.3 CLINICAL EFFECTIVENESS Studies comparing the c l i n i c a l effectiveness of different groups of mental health professionals are not numerous, but those which are available generally indicate that for the s p e c i f i c tasks evaluated, the professions can provide equally competent service i n the same amount of time. Returning to the meta-analysis of psychotherapy outcome studies referred to e a r l i e r , Smith & Glass (1977) report that i n t h e i r analysis of 375 studies using therapists trained i n psychiatry, psychology, or education, no d i f f e r e n c e s i n p r o f e s s i o n a l e f f e c t i v e n e s s emerged. Likewise, Casey and Berman's (1985) meta-analysis of the effectiveness of psychotherapy with children revealed that neither the experience, education, or sex of the t h e r a p i s t was s i g n i f i c a n t l y related to treatment success. Looking at studies designed s p e c i f i c a l l y to compare one profession against another, results are s i m i l a r to those of the meta-analyses, with the o c c a s i o n a l r e s u l t f a v o r i n g the \"junior\" profession. Knesper, 94 Pagnucco, and Wheeler (1985) s t u d i e d the d i a g n o s t i c s k i l l s of p s y c h i a t r i s t s , psychologists, and s o c i a l workers i n the United States. As part of a larger study i n c l i n i c a l a c t i v i t i e s , to be reported i n greater d e t a i l below, the investigators surveyed a sample of 3,239 ps y c h i a t r i s t s , 2,917 psychologists, and 1,585 s o c i a l workers. Subjects were presented with four written vignettes from the DSM-III Case Book and asked to judge severity l e v e l and select the \"correct\" diagnosis; no s i g n i f i c a n t differences were found between groups. Clavelle and Turner (1980) investigated the a b i l i t y of three groups of mental health workers to make decisions i n an intake interview as to whether a c l i e n t was s u i c i d a l , needed m e d i c a t i o n , and needed ho s p i t a l i z a t i o n . The groups compared were 32 paraprofessionals (trained as intake workers i n a community mental health centre on a U.S. Army p o s t ) , 11 s o c i a l workers (M.S.W.), and 13 psychologists (Ph.D.). Subjects conducted a simulated intake i n t e r v i e w . Each c l i e n t was represented by a stack of index cards with the name of a c l a s s i f i c a t i o n of information on the front and the corresponding c l i e n t information on the back. Subjects began with standard i d e n t i f y i n g information and then proceeded through the cards as they judged appropriate, made decisions i n t h e t h r e e c a t e g o r i e s , and r a t e d t h e i r c e r t a i n t y . The paraprofessionals and professionals showed equal consensus i n decision-making. The psychologists were the most confident i n t h e i r decision-making but only when appropriate; they seemed to be able to discriminate b e t t e r than the p a r a p r o f e s s i o n a l s between the c l e a r - c u t and the ambiguous i s s u e s . S o c i a l workers were more confident than the paraprofessionals but less confident than the psychologists. S i m i l a r l y , Newson-Smith and H i r s c h (1979) compared the e f f e c t i v e n e s s of s o c i a l workers and psychiatrists i n evaluating 60 patients admitted to a London hospital as attempted suicides. Patients were interviewed f i r s t by a s o c i a l worker and then by a p s y c h i a t r i s t , both of whom were asked to carry out a c l i n i c a l assessment and f i l l out a r a t i n g schedule at the end of the i n t e r v i e w . Evaluations were compared against a t h i r d interview conducted l a t e r the same day by a research p s y c h i a t r i s t , who administered two standardized mental examinations. Social workers and p s y c h i a t r i s t s showed a high l e v e l of agreement with the standardized measures i n the areas of personality abnormality, presence of physical i l l n e s s , necessity for a psychiatric opinion before discharge, and necessity to admit. Social workers showed more disagreement with the standardized measures i n r a t i n g the presence of mental i l l n e s s i n ambiguous situations, tending to rate i t as present more often than the p s y c h i a t r i s t s for those patients whose standard scale scores f e l l i n the middle range. Follow-up data on f u r t h e r s u i c i d e attempts tended to support the s o c i a l workers' o r i g i n a l judgments as being as v a l i d as those of p s y c h i a t r i s t s . The results i n d i c a t e d that s o c i a l workers appeared to be more s k i l l e d than the p s y c h i a t r i s t s at recommending support services upon discharge. The authors conclude that s o c i a l workers could undertake to deal with some or a l l of the attempted suicide intake r e f e r r a l s , with a p s y c h i a t r i s t available for consultations about urgent problems. Psychiatric nurses have been the focus of several investigations of t h e i r competence as therapists. Marks, Hallam, P h i l p o t t , and Connolly (1975) trained f i v e psychiatric nurses i n an 18-month course to become behavioral therapists with adult neurotic patients i n a London hospital outpatient department. Training began with two weeks of introductory lectures and continued with small group lectures throughout t r a i n i n g . The t r a i n i n g program followed the apprenticeship model used i n t r a i n i n g 96 p s y c h i a t r i s t s . Trainees observed t h e i r s upervisors carrying out treatment and then gradually took over the therapeutic r o l e to become the p r i n c i p a l therapist. Supervision occupied almost 50 percent of trainees' time at the s t a r t of t r a i n i n g but dropped to only a half-hour consultation per week when therapists were seconded to hospitals two years l a t e r . Patients presented with phobic and obsessive-compulsive d i s o r d e r s , s e x u a l d y s f u n c t i o n , s t u t t e r i n g , e n u r e s i s , and hypochondriasis. A l l patients were rated on target behaviors before and after treatment and at follow-up one, s i x , and 12 months l a t e r . The investigators compared the results obtained by the psychiatric nurses with outcome st u d i e s i n v e s t i g a t i n g comparable behaviour therapy procedures. They reported that the psychiatric nurses proved to be as e f f e c t i v e as p s y c h i a t r i s t s , p s y c h o l o g i s t s and medical students performing s i m i l a r techniques. Paykel, Mangen, G r i f f i t h , and Burns (1982) compared ps y c h i a t r i s t s and psychiatric nurses i n the management of 71 adult neurotic patients seen at an outpatient c l i n i c i n London. The patients were randomly assigned to outpatient care by a p s y c h i a t r i s t at the c l i n i c or home v i s i t i n g by a psychiatric nurse. Patients were evaluated every s i x months for 18 months. The investigators found no differences between the e f f e c t i v e n e s s of the two modes of service on symptoms, s o c i a l adjustment, or family burden; however, patients seen by the psychiatric nurses showed a marked r e d u c t i o n i n o u t p a t i e n t contacts with ps y c h i a t r i s t s at the c l i n i c , had a higher rate of discharge from the c l i n i c , and reported greater s a t i s f a c t i o n with treatment. 97 6.4 PATTERNS OF PRACTICE In an attempt to determine the extent to which' each of the mental health professions provides psychotherapy, Blum & R e d l i c h (1980) surveyed 586 p s y c h i a t r i s t s , psychologists, s o c i a l workers, psychiatric nurses, and mental health workers i n 25 treatment f a c i l i t i e s and i n p r i v a t e p r a c t i c e i n south-central Connecticut. Subjects were asked whether they spent at least one hour per week i n any of the following a c t i v i t i e s : i n d i v i d u a l therapy, group therapy, family\/couple therapy, l i a i s o n for patients, or i n t a k e e v a l u a t i o n . A l l groups reported providing services m a l l categories, with the exception that no data were gathered for p s y c h i a t r i s t s i n the l a s t two c a t e g o r i e s . The professions provided i n d i v i d u a l , group, and family\/couple therapy at the f o l l o w i n g r a t e s r e s p e c t i v e l y : p s y c h i a t r i s t s (89%, 40%, 5 9 % ) , p s y c h o l o g i s t s (70%, 53%, 52%), s o c i a l workers (84%, 49%, 63%), psychiatric nurses (64%, 64%, 41%), and mental health workers (50%, 64%, 44%). The authors comment that the sharing of the task of psychotherapy among the professional groups represents a change i n the deployment of manpower. They speculate that t h i s does not represent a retreat from psychotherapy by p s y c h i a t r i s t s but rather an expansion of the functions of other professions. They suggest that the greater involvement of nurses i n providing psychotherapy for inpatients perhaps stems from the movement to replace custodial care with a more active treatment program and, s i m i l a r l y , the extensive involvement of psychologists and s o c i a l workers i n p r o v i d i n g psychotherapy for outpatients i s t i e d to the considerable expansion of o u t p a t i e n t c l i n i c s , where t h e s e two professions tend to be heavily concentrated. McGuire (1980) examined the d i s t r i b u t i o n of the core mental health d i s c i p l i n e s using employment data obtained from national professional . 98 organizations, the National I n s t i t u t e of Mental Health, and the 1978 President's Commission on Mental Health. McGuire found that the mix of professions providing mental health services across f a c i l i t i e s varied a great deal. In hospital settings, medical personnel (psychiatrists and nurses) were more heavily used. Relative to other groups, p s y c h i a t r i s t s were most heavily used i n general hospitals. In outpatient settings, such as f r e e - s t a n d i n g c l i n i c s and CMHC's, psychologists and s o c i a l workers predominated. The r a t i o of ps y c h i a t r i s t s to psychologists (M.A. and above), was very close to 1:1 across a l l f a c i l i t i e s , but ranged from 3.17 for general hospitals to .57 for CMHC's to .44 for free-standing outpatient c l i n i c s . Psychotherapy i n private practice was dominated by psychi a t r i s t s and psychologists, although s o c i a l workers also formed part of the private practice manpower pool. McGuire reports that at that time i n the United States, there were about 10,000 FTE private p r a c t i c e p s y c h i a t r i s t s and 6,000 to 8,000 FTE p r i v a t e p r a c t i c e psychologists. Data for s o c i a l workers did not permit derivation of an FTE indicator, but McGuire notes that of the 8,500 s o c i a l workers doing some private practice, 2,000 worked more than 20 hours per week i n p r i v a t e p r a c t i c e . P s y c h i a t r i c nurses represented a very small percentage of private practice manpower, with fewer than 300 nurses i n either f u l l - t i m e or part-time private practice. Knesper, Pagnucco, & Wheeler (1985) studied the case mixes of ps y c h i a t r i s t s , psychologists, and s o c i a l workers i n the United States. The investigators distributed a questionnaire to a selected sample of each profession. Therapists were instructed to choose patients for whom they had provided direct treatment, defined as a series of face-to-face p r o f e s s i o n a l contacts f o r therapy r a t h e r than for evaluation or consultation. Subjects were placed into one of two groups; the f i r s t 99 group answered questions about the l a s t f i v e patients seen i n i n d i v i d u a l treatment and the second group answered questions about the l a s t f i v e patients discontinuing treatment. In analyzing the survey r e s u l t s , the i n v e s t i g a t o r s d i v i d e d mental di s o r d e r s i n t o MSC's (More Severe Con d i t i o n s : s c h i z o p h r e n i a , major depressive disorders, and manic disorders) and LSC's (Less Severe C o n d i t i o n s : anxiety d i s o r d e r s , neuroses, personality disorders, and relationship problems). They found that the LSC's dominated the case mix of a l l provider groups i n a l l p r a c t i c e s e t t i n g s . In the case of MSC's i n the CMHC s e t t i n g , p s y c h i a t r i s t s saw twice as many MSC's but h a l f as many LSC's as ps y c h o l o g i s t s and s o c i a l workers but for MSC's treated i n hospital settings, the three provider groups did not d i f f e r appreciably i n case mix. T a k i n g i n t o account v a r i o u s f u n d i n g and apportionment arrangements, the authors conclude that i n less organized s e t t i n g s , simple substitution seems to occur for LSC's, and i n more organized settings, complex substitution appears to occur for MSC's as we l l . Two studies have examined the s t a f f i n g patterns of CMHC's i n the United States (Perls, winslow, & Pathak, 1980; McGuire, 1980) and have found that apportionment of professionals appears to be determined not only by need for a pa r t i c u l a r d i s c i p l i n e , as one would expect, but also by the preferences of the directors for one d i s c i p l i n e over another and by economic considerations. Perls et a l . surveyed 278 mental health centres and compared the s t a f f i n g patterns of the centres by type of educational background of the director. The investigators found that c e n t r e s whose d i r e c t o r was a p s y c h i a t r i s t \/ p h y s i c i a n employed a s i g n i f i c a n t l y higher median number of f u l l - t i m e p s y c h i a t r i s t s than centres whose d i r e c t o r was from another d i s c i p l i n e . Centres whose director was a Ph.D.-level psychologist employed a somewhat higher 100 median number of psychologists but not s i g n i f i c a n t l y so. However, the tendency of centre d i r e c t o r s to employ more s t a f f of t h e i r own professional background did not hold for s o c i a l workers; centres with a psy c h i a t r i s t as director employed s i g n i f i c a n t l y more s o c i a l workers than centres whose directors were from other professional backgrounds. McGuire (1980) investigated patterns of s u b s t i t u t a b i l i t y for the s e r v i c e s of p s y c h i a t r i s t s and psychologists i n CMHC's. Using NIMH survey data on s t a f f i n g for a sample week i n 1976, McGuire computed the r a t i o of a l l hours worked by psych i a t r i s t s taken alone to a l l hours worked by psy c h i a t r i s t s and psychologists taken together. Carefully c o n t r o l l i n g possible sources of confounding, McGuire examined the extent to which the r e l a t i v e use of the two professions' services could be a t t r i b u t e d t o s u b s t i t u t a b i l i t y between the two i n p u t s . Results indicated that as much as 85 percent of the variance i n the d i s t r i b u t i o n of the two professions could be attributed to simple substitution. McGuire separated the independent v a r i a b l e s i n t o four c a t e g o r i e s : \" d i f f e r e n t outputs,\" \"ambiguous,\" \"simple s u b s t i t u t a b i l i t y , \" and \"complex s u b s t i t u t a b i l i t y . \" In the f i r s t category, different outputs, McGuire found that the percentage of patients treated on an inpatient basis and the percentage of patients with more \"severe\" diagnoses had no s i g n i f i c a n t effect on r e l a t i v e rates of p s y c h i a t r i s t and psychologist s t a f f i n g . However, CMHC's i n catchment areas with more young residents used s i g n i f i c a n t l y more psychologists, and CMHC's i n catchment areas with higher incomes used s i g n i f i c a n t l y more p s y c h i a t r i s t s . In the second, ambiguous, category, source of funds seemed to have a powerful effect on s t a f f i n g patterns. Centres with a high l e v e l of grants and payments from medicare, medicaid, and private insurance made r e l a t i v e l y heavier use of p s y c h i a t r i s t s . Conversely, centres which r e l i e d on fees 101 and centres based i n private psychiatric hospitals made r e l a t i v e l y more use of psychologists. In the t h i r d category, simple s u b s t i t u t a b i l i t y , as i n P e r l s et a l . , the d i s c i p l i n e of the centre director had a considerable effect on the r a t i o of psych i a t r i s t s and psychologists. A l l other directors use fewer psyc h i a t r i s t s and more psychologists than do p s y c h i a t r i s t directors with the single exception of other physician d i r e c t o r s . Also i n t h i s category, none of the variables measuring re g u l a t o r y c l i m a t e f o r p s y c h o l o g i s t s i n p r i v a t e p r a c t i c e had a si g n i f i c a n t effect. In the fourth category, complex s u b s t i t u t a b i l i t y , a comparison was made of the r e l a t i v e use of p s y c h i a t r i s t s and ps y c h o l o g i s t s with the r e l a t i v e use of a l l types of workers. The results indicated that i n centres where psych i a t r i s t s and psychologists are replaced by other mental health workers, more psychologists are replaced. Conversely, i n centres where work i s done with a heavier use of p s y c h i a t r i s t s and p s y c h o l o g i s t s , p s y c h o l o g i s t s increase t h e i r percentage of the t o t a l work force more than do p s y c h i a t r i s t s . This l a s t f i n d ing suggests that when services are expanded, mental health workers providing services for which simple substitution i s possible (such as psychotherapy) are hired and when services are contracted, mental health workers providing services for which simple substitution i s not p o s s i b l e (such as medication p r e s c r i p t i o n and review) are retained. 6.5 PROFESSIONS AS PSYCHOTHERAPISTS COMPARED In summary, when the public was asked to rate the four professions i n terms of perceived prestige, p s y c h i a t r i s t s were consistently given the highest rating; but when the professions were considered i n terms of d e s i r a b i l i t y as a psyc h o t h e r a p i s t , subjects were less consistent, 102 sometimes choosing one profession and sometimes another. When two d i s c i p l i n e s , p s y c h i a t r i s t s and psychologists, were asked to rate each other's competence, they did not have a very high opinion of each other. The other mental health workers, s o c i a l workers and nurses, who also r a t e d the two d i s c i p l i n e s , gave a more balanced view, g i v i n g ps y c h i a t r i s t s higher marks i n diagnostics and medication management and psychologists higher marks i n psychotherapy, counselling, and testing. Studies which reviewed c l i n i c a l a t t i t u d e s of psychotherapists across d i s c i p l i n e s found that attitudes varied more as a function of the theoretical school of psychotherapy, gender of the psychotherapists, and years of professional experience than of professional d i s c i p l i n e . In comparing a t t i t u d e s toward treatment s e t t i n g s , s p e c i f i c a l l y the community mental health movement, psychologists and s o c i a l workers were found to be the most po s i t i v e and p s y c h i a t r i s t s least p o s i t i v e , with nurses f a l l i n g above the p s y c h i a t r i s t s but below the other two d i s c i p l i n e s . While t h i s r e s u l t might have been p r e d i c t e d from an examination of t r a i n i n g program emphases, another study of c l i n i c a l a t t i t u d e s , whether to t r e a t or r e f e r a p s y c h o t i c p a t i e n t , seems surprising i n i t s f i n d i n g that s o c i a l workers are far more l i k e l y to choose to treat than are psychologists or p s y c h i a t r i s t s , unless we consider that the services being offered might have been community l i v i n g support systems, for which the s o c i a l workers' t r a i n i n g would indeed make them the best-prepared to r e t a i n the patient. In studies of c l i n i c a l effectiveness, i n v e s t i g a t o r s found that professions are most confident and accurate i n those functions for which they have received the most t r a i n i n g and have had the most experience; however, i n terms of absolute effectiveness, there i s no evidence that the p r o f e s s i o n s d i f f e r a ppreciably e i t h e r as d i a g n o s t i c i a n s or 10 3 psychotherapists nor that the professions d i f f e r i n the amount of time required to deliver psychotherapy services. In the study comparing p s y c h i a t r i s t s and psychiatric nurses as psychotherapists for chronic neurotic outpatients, i t was found that c l i e n t s showed more improvement with supportive counselling i n t h e i r homes with a psychiatric nurse than with b r i e f medication checks at a c l i n i c with a p s y c h i a t r i s t , but the result could c e r t a i n l y be as much a function of the type of service offered as of the p a r t i c u l a r d i s c i p l i n e o f f e r i n g i t . When stu d i e s investigating patterns of practice are reviewed, study results indicate that a l l of the four core mental health d i s c i p l i n e s are p r o v i d i n g psychotherapy across a wide variety of treatment settings. In less organized settings, such as private practice and outpatient c l i n i c s , simple substitution appears to occur for LSC's and i n more organized settings, such as hospitals, complex substitution appears to occur for MSC's as well. Studies of s t a f f i n g patterns indicate that while each profession appears to have s k i l l s which are unique to that profession, there i s s u f f i c i e n t overlap i n s k i l l s across professions that factors such as funding arrangements and preferences of f a c i l i t y administrators as w e l l as professional d i s c i p l i n e have a considerable influence on al l o c a t i o n of st a f f positions. 104 CHAPTER SEVEN SUBSTITUTION AND THE TREATMENT OF MENTAL DISORDERS In assessing the f e a s i b i l i t y of simple substitution i n private practice psychiatry, we next consider the degree to which treatment practices permit substitution of other mental h e a l t h workers as providers of s e r v i c e s c u r r e n t l y delivered by psy c h i a t r i s t s . Chapter Seven examines the common patterns of treatment practice i n an attempt to develop statements about the range of possible substitutions. Table VIII presents i n outline form the accepted treatment modes and management modes for mental disorders and then relates these treatment modes and management modes to an estimate of simple substitution p o s s i b i l i t i e s . I have used the ICD-9-CM c l a s s i f i c a t i o n (WHO, 1978a) system rather than the DSM-III c l a s s i f i c a t i o n system because although the l a t t e r system i s the one used i n B r i t i s h Columbia, the former c l a s s i f i c a t i o n system i s the one used i n Manitoba, which i s the source for the data used i n the analysis of substitutable share i n the present study. In using the term \"treatment mode,\" my intention i s to indicate whether a p a r t i c u l a r mental d i s o r d e r i s t y p i c a l l y treated using psychotherapy, pharmacotherapy, or a combination of psychotherapy and pharmacotherapy. In reviewing the treatment outcome l i t e r a t u r e , observing treatment practices, and interviewing p r a c t i c i n g c l i n i c i a n s , I have t r i e d to include the broadest range of treatment practices i n order to encompass those instances where conventional wisdom even i f not necessarily experimental evidence might m i l i t a t e against substitution. For example, i n the case of the treatment of bulimia (Diagnostic Code: 307) there i s a school of treatment theory which considers b u l i m i a a depressive equivalent and recommends anti-depressant medications as the treatment of choice; although the outcome l i t e r a t u r e does TABLE V I I I S u b s t i t u t i o n and t h e Treatment o f M e n t a l D i s o r d e r s DIAGNOSTIC cone (ICP-9-CH) TREATMENT MANAGEMENT SIMPLE SUBSTITUTION Psychotherapy Pharmacotherapy Cosfeined Single Therapy Favored Favored Favored Therapist Teas Low Moderate H i gh Organic Psychotic Conditions (290-294) 290 S e n i l e & P r e s e n i l e O rgan i c Psychoses X X X 291 A l c o h o l i c Psychoses X X X 292 Drug P sychoses X X X 293 T r a n s i e n t Psychoses X X X 294 O the r O r g a n i c Psychoses X X X Other Psychoses (295-299) 295 S c h i z o p h r e n i c Psychoses X X X X 296 A f f e c t i v e Psychoses X X X X 297 P a r a n o i d S t a t e s X X X X 298 O the r Nono rgan i c Psychoses X X X X 299 Psychoses with O r i g i n S p e c i f i c to C h i l d h o o d X X X X Neurotic Disorders, Personality Disorders, and Other Nonpsychotic Mental Disorders (300-316) 300 N e u r o t i c D i s o r d e r s X X X X X 301 P e r s o n a l i t y D i s o r d e r s X X X 302 Se xua l D e v i a t i o n s and D i s o r d e r s X X X 303 A l c o h o l Dependence X X X X X 304 Drug Dependence X X X X X 305 Nondependent Drug Abuse X X X X 306 Somatoform D i s o r d e r s X X X X X 307 S p e c i a l Symptoms NEC^ X X X X X 308 A cu t e R e a c t i o n t o S t r e s s X X X X X X 309 Ad jus tment R e a c t i o n X X X 310 Nonp s y cho t i c D i s o r d e r s F o l l o w i n g B r a i n Damage X X X X X 311 D e p r e s s i v e D i s o r d e r NEC X X X x x X 312 Conduct D i s o r d e r NEC X X X 313 Emo t i o n a l D i s t u r b a n c e o f Ch i l d hood \/Ado l e s c en ce X X X X X X 314 H y p e r k i n e t i c Syndrome o f Ch i l d hood X X X X X 315 S p e c i f i c De l a y s i n Development X X X 316 Psychosomat i c D i s o r d e r s EC^ X X X X X Mental Retardation (317-319) 317 M i l d M e n t a l R e t a r d a t i o n X X X X X 318 Othe r S p e c i f i e d Menta l R e t a r d a t i o n X X X X X 319 U n s p e c i f i e d M e n t a l R e t a r d a t i o n X X X X X Conditions Not Attributable to a Mental Disorder (V) V61 Othe r F a m i l y C i r cums tances X X X V62 Othe r P s y c h o s o c i a l C i r cums tances X X X V63 - V71 M e d i c a l o r I nde te rm ina te P rocedu res X *NEC< Not E l s ewhe re C l a s s i f i e d 106 not f i n d evidence for the effectiveness of th i s treatment mode i n reducing b u l i m i c binge-eating behavior (Huon & Brown, 1984), I have indicated pharmacotherapy as a possible treatment mode for t h i s disorder. On the other hand, I have not included psychotherapy as a possible treatment mode where the outcome l i t e r a t u r e does not support i t s effectiveness. This has the effect of making my potential substitution ranges extremely conservative. In using the term \"management mode,\" my intention i s to indicate whether a p a r t i c u l a r mental disorder i s t y p i c a l l y treated by a single therapist or by a therapy team. Where I have indicated that a disorder might be treated by a single therapist, i t has been my intention to c i t e those instances where i t i s common practice for a single therapist to be responsible for the treatment needs of a patient either i n an outpatient setting or an inpatient medical or other i n s t i t u t i o n a l setting. Where I have indicated that a disorder might be t r e a t e d by a therapy team, i t has been my intention to include those instances where a combination of mental h e a l t h workers i s t y p i c a l l y responsible for the treatment needs of a patient either i n an outpatient s e t t i n g or an inpatient psychiatric setting; however, I have meant to exclude those treatment situations where a single mental health worker i s responsible for the mental health treatment needs of a patient as a member of a team of workers from outside the mental health d i s c i p l i n e s , such as non-psychiatric medical p r a c t i t i o n e r s , teachers, and welfare agency s o c i a l workers. Instead, I have assigned t h i s l a t t e r category of treatment si t u a t i o n to the single therapist management mode. As with treatment modes, I have t r i e d to include the broadest range of management modes i n an attempt to include those treatment s i t u a t i o n s which would l i m i t the p o s s i b i l i t i e s f o r simple substitution. With regard to the relationship between treatment practices and the p o s s i b i l i t i e s for simple substitution, consideration of the combinations of 107 treatment modes and management modes which appear to emerge from an examination of patterns of treatment practice leads me to suggest three levels of substitution p o s s i b i l i t i e s : \"low,\" \"moderate,\" and \"high.\" To the low s u b s t i t u t a b i l i t y category, I would suggest assigning those mental disorders which are t y p i c a l l y treated by a therapy team; given t h i s treatment s i t u a t i o n , substitution would necessarily need to be complex rather than simple. Also to the low s u b s t i t u t a b i l i t y category, I would suggest assigning those disorders which can be treated by a single therapist but where the treatment of choice i s most commonly pharmacotherapy or a combination of psychotherapy and pharmacotherapy; i n t h i s instance the single therapist would n e c e s s a r i l y need t o be a p s y c h i a t r i s t . To the moderate s u b s t i t u t a b i l i t y category, I would suggest assigning those disorders for which, depending upon the phase of the disorder or the s u b - c l a s s i f i c a t i o n of the d i s o r d e r , psychotherapy and single therapist are sometimes, but not always, the favored treatment and management modes. F i n a l l y , to the high s u b s t i t u t a b i l i t y category, I would suggest assigning those disorders for which psychotherapy and s i n g l e t h e r a p i s t are t y p i c a l l y the p r e f e r r e d treatment and management modes. In the review of treatment practices which follows, I have chosen to begin with the two mental d i s o r d e r s which accounted f o r the greatest percentage of b i l l i n g s by private practice ps y c h i a t r i s t s to the Manitoba Health Services Commission i n 1984, Neurotic Disorders (Diagnostic Code: 300) and Depressive Disorders (Diagnostic Code: 311). I w i l l review the outcome l i t e r a t u r e f o r these two d i s o r d e r s i n greater d e t a i l as they c o n s t i t u t e some 50 percent of the costs of private practice psychiatry service delivery. I then move to a discussion of two groups of disorders which appear to have a very low p o s s i b i l i t y for simple substitution, Organic Psychotic Conditions (Diagnostic Codes: 290-294) and Other Psychoses 108 (Diagnostic Codes: 295-299). I then conclude with a review of treatment p r a c t i c e s f o r P e r s o n a l i t y Disorders (Diagnostic Code: 301), Other Nonpsychotic Mental Disorders (Diagnostic Codes: 302-316), M e n t a l Retardation (Diagnostic Codes: 317-319), and Conditions Not Attributable to a Mental Disorder (the so-called \"V\" Codes). Depressive Disorder NEC1 (Diagnostic Code: 311) \"States of depression, usually of moderate but occasionally of marked i n t e n s i t y , which have no s p e c i f i c a l l y manic-depressive or other psychotic depressive features and which do not appear to be associated with s t r e s s f u l events or other features specified under Neurotic Depression [Diagnostic Code: 300.4].\" 2 Studies which have compared the effectiveness of psychotherapy and medication generally f i n d that psychotherapy i s at least as eff e c t i v e as medication. McLean and Hakstian (1979) randomly assigned 178 moderately depressed c l i e n t s to ten weeks of psychotherapy, cognitive-behaviour therapy (CBT), pharmacotherapy, or relaxation therapy (treatment control condition). In addition to showing d i f f e r e n t i a l drop-out rates of 5 percent for CBT and 26 to 36 percent for the three other conditions, results showed CBT to be superior on nine out of ten measures at the end of treatment and marginally s u p e r i o r a t the three-month f o l l o w - u p . Psychotherapy, which was psychodynamic i n technique, performed most poorly on most outcome measures at both evaluation periods and there were no s i g n i f i c a n t differences between pharmacotherapy and relaxation therapy on any outcome measures. Blackburn, Bishop, Glen, Whalley, and C h r i s t i e (1981) and Blackburn and Bishop (1983) randomly assigned 64 depressed patients to cognitive therapy, antidepressant therapy, or a combination of the two. Subjects were treated either i n general practice or i n a hospital outpatient department. The r e s u l t s i n d i c a t e d greater improvement on a l l parameters with cognitive 109 methods than with pharmacological agents. The combination of both methods of treatment was more e f f e c t i v e w i t h the more c h r o n i c a l l y i l l and more symptomatic h o s p i t a l outpatients, but not s i g n i f i c a n t l y more e f f e c t i v e f o r the patients treated i n general p r a c t i c e -Rush, Beck, Kovacs, and Hollon (1977) compared cognitive psychotherapy w i t h a n t i d e p r e s s a n t s and found s i g n i f i c a n t l y greater effectiveness f or cognitive therapy. Again, there were s i g n i f i c a n t differences i n drop-out r a t e : 5 percent f o r the cognitive psychotherapy group and 32 percent for the pharmacotherapy group. Kovacs, Rush, Beck, and Hollon (1981) reported on a one-year f o l l o w - u p with the Rush et a l - (1977) subjects. Although the cognitive psychotherapy group was s t i l l superior to the medication group, the two groups were not now s t a t i s t i c a l l y d i f f e r e n t . However, treatment gains had been maintained, those intergroup differences which d i d occur always favored the cognitive psychotherapy group, and the medication group was twice as l i k e l y to relapse ( i . e . , to obtain a score over 16 on the Beck Depression Inventory at some time during the year). As i n the Blackburn studies, Murphy, Simons, Wetzel, and Lustman (1984) found cognitive psychotherapy to be as e f f e c t i v e but not more e f f e c t i v e than pharmacotherapy i n a study which assigned p a t i e n t s t o e i t h e r c o g n i t i v e psychotherapy, pharmacotherapy, cognitive psychotherapy plus pharmacotherapy, or cognitive psychotherapy plus placebo- Williams (1984), reviewing the studies by Blackburn et a l . , Kovacs et a l . , McLean and Hakstian, Murphy et a l . , and Rush et a l . , concludes that f o r mildly to moderately depressed p a t i e n t s , cognitive psychotherapy appears to be at l e a s t as e f f e c t i v e as pharmacotherapy i n p r o d u c i n g change on outcome measures taken a t the termination of treatment and appears, as w e l l , to have the added advantage of a lower drop-out rate and a lower relapse rate- He q u a l i f i e s h i s conclusions with the observation that f o r severely depressed pa t i e n t s , a combination of 110 cognitive psychotherapy and pharmacotherapy may be more e f f e c t i v e than cognitive psychotherapy alone. Studies which have compared the effectiveness of combined treatment with psychotherapy alone or medication alone sometimes f i n d an additive effect and sometimes do not. Beck, Hollon, Young, Bedrosian, and Budenz (1985) assigned 33 outpatients to either CBT or CBT plus pharmacotherapy. Both groups showed s t a t i s t i c a l l y s i g n i f i c a n t and c l i n i c a l l y meaningful decreases i n depressive symptoms. No differences emerged between the two groups i n terms of the magnitude of the decrease. The authors conclude that the addition of the antidepressant medication did not improve the response obtained by CBT alone. Weissman, Kasl, & Klerman, (1976) studied 150 women who were f i r s t given 4 to 6 weeks of medication treatment, then two months of medication treatment with either weekly supportive psychotherapy or a brief monthly interview, and then s i x months of either medication, placebo, or no medication. The authors r e p o r t t h a t medication prevented symptom r e t u r n but d i d not have a d i f f e r e n t i a l effect on s o c i a l functioning; psychotherapy, on the other hand, did not prevent symptom return but did improve s o c i a l functioning. In a one-year follow-up, the results showed no s i g n i f i c a n t differences between the medication and the psychotherapy groups; however, the results are confounded because the experimental conditions were no longer controlled i n the follow-up period and patients sought a variety of treatments. In a second study, Weissman, Prusoff, and DiMascio (1979) again compared the effectiveness of medication and psychotherapy and the combination of the two. Subjects were 96 outpatients randomly assigned for 16 weeks to e i t h e r psychotherapy, pharmacotherapy, psychotherapy plus pharmacotherapy, or nonscheduled psychotherapy (patients were assigned to a p s y c h i a t r i s t and were t o l d that they should contact the therapist i f they f e l t the need for treatment). Results showed that the combination of antidepressants and short-term 111 psychotherapy was more eff e c t i v e than either treatment alone or than the nonscheduled psychotherapy; medication and psychotherapy alone were about equally e f f e c t i v e . Teasdale, Fennell, Hibbert, and Amies (1984) assigned 34 patients to treatment groups of medication alone or medication plus i n d i v i d u a l cognitive therapy. At the completion of treatment, patients receiving cognitive therapy plus medication were s i g n i f i c a n t l y l e s s depressed than those r e c e i v i n g medication alone. At the three-month follow-up assessment cognitive therapy plus medication patients no longer dif f e r e d s i g n i f i c a n t l y from the medication alone group. I t i s unfortunate that t h i s study did not also include a cognitive therapy alone group. Bellack, Hersen, and Himmelhoch (1981) randomly assigned 125 depressed women to four experimental conditions: antidepressant alone, antidepressant plus s o c i a l s k i l l s t r a i n i n g , s o c i a l s k i l l s t r a i n i n g plus placebo, and psychotherapy plus placebo. The authors found that each treatment produced s t a t i s t i c a l l y s i g n i f i c a n t and c l i n i c a l l y meaningful changes i n symptoms but that medication did not add to the e f f e c t i v e n e s s of the s o c i a l s k i l l s treatment. In addition, the group receiving s o c i a l s k i l l s t r a i n i n g plus placebo had the lowest l e v e l of a t t r i t i o n (24 percent compared with 53 percent for the antidepressant alone group) and had the highest proportion of patients who were s i g n i f i c a n t l y improved at the six-month follow-up. Conte, Plutchik, Wild, and Karasu (1986) reviewed 11 controlled studies reported between 1974 and 1984, including several of those already mentioned (Beck et a l . , 1985; Bellack et a l . , 1981; Blackburn et a l . , 1981, 1983; and Murphy et a l . , 1984), to determine whether combined psychotherapy and pharmacotherapy i s superior to either treatment alone. Using a s t a t i s t i c a l approach to analyze the findings of the studies, the authors evaluated the quality of each study and assigned weights to each outcome. The results 112 indicated that the combined active treatments (medication plus psychotherapy) were appreciably more effec t i v e than placebo conditions but only s l i g h t l y and non-significantly superior to psychotherapy alone or pharmacotherapy alone. F i n a l l y , to conclude, i n a study which indicates that there may be an in t e r a c t i v e effect between p e r s o n a l i t y t r a i t s and p r e f e r r e d treatment, Simons, Lustman, Wetzel, and Murphy (1985) found a relationship between degree of learned resourcefulness as measured by the Self-Control Schedule (SCS) and response to cognitive psychotherapy or anti-depressant medication. In t h e i r study, 35 moderately depressed patients were assigned to either a cognitive psychotherapy or an antidepressant pharmacotherapy condition. The results showed that both groups improved s i g n i f i c a n t l y by the end of treatment. However, subjects e n t e r i n g c o g n i t i v e psychotherapy with r e l a t i v e l y high SCS scores did better than subjects with low SCS scores while subjects e n t e r i n g pharmacotherapy with low SCS scores did better than subjects with high SCS scores. In the treatment of Depressive Disorder, to summarize the review of outcome l i t e r a t u r e presented above, psychotherapy, pharmacotherapy, and combined psychotherapy\/pharmacotherapy each appear to be more eff e c t i v e than placebo conditions, but t h e i r r e l a t i v e and absolute effectiveness seem to be related to the p a r t i c u l a r technique employed and to the p a r t i c u l a r phase of the disorder being treated. With regard to treatment mode, c o g n i t i v e b e h a v i o r therapy appears to be more e f f e c t i v e than other types of psychotherapy. Anti-depressant medications appear to be more eff e c t i v e than anti-anxiety medications (Catalan, Gath, Edmonds, & Ennis, 1984; Gullick & King, 1979; Weissman & Klerman, 1977). Psychotherapy treatments tend to produce a lower drop-out rate than pharmacotherapy treatments. Combined treatments have produced greater improvement i n some studies with the more severely depressed patients but results are not consistent for the less severely depressed patients. F i n a l l y , there appears to be an interaction 113 .between the personality type of the patient and the r e l a t i v e effectiveness of either psychotherapy or pharmacotherapy. With regard to management mode, patients diagnosed as Depressive Disorder are t y p i c a l l y t r e a t e d i n an outpatient s e t t i n g , usually by a single therapist, but occasionally, i f the condition i s severe and\/or there are s u i c i d a l features, the patient may be t r e a t e d i n an i n p a t i e n t psychiatric setting. Based on t h i s pattern of treatment practices, I would suggest that simple substitution p o s s i b i l i t i e s for Diagnostic Code 311 be considered to f a l l i n the moderate range. Neurotic Disorder (Diagnostic Code: 300) \"Neurotic Disorders are mental di s o r d e r s w i t h o u t any demonstrable organic basis i n which the patient may have considerable insight and has unimpaired r e a l i t y t e s t i n g , i n that he u s u a l l y does not confuse h i s morbid subjective experiences and fantasies with external r e a l i t y . Behavior may be g r e a t l y a f f e c t e d although u s u a l l y remaining w i t h i n s o c i a l l y a c c e p t a b l e l i m i t s , but p e r s o n a l i t y i s not disorganized. The p r i n c i p a l manifestations include excessive anxiety, h y s t e r i c a l symptoms, obse s s i o n a l and compulsive symptoms, and depression.\" 3 With regard to the treatment of the s u b - c l a s s i f i c a t i o n Phobic States, a number of s t u d i e s and reviews of s t u d i e s have found that b e h a v i o r modification psychotherapy techniques and cognitive behavior psychotherapy techniques are at l e a s t as e f f e c t i v e as pharmacotherapy and combined psychotherapy\/pharmacotherapy treatments. Linden (1981) reviewed 11 c o n t r o l l e d s t u d i e s of i n v i v o exposure f o r agoraphobia and reported s i g n i f i c a n t improvement and maintenance of improvement i n the majority of treated patients, with the lowest improvement rate reported as 58 percent. S i m i l a r l y , Carney (1985) notes that recent reviews of studies employing i n vivo exposure with agoraphobics have concluded that approximately 65 to 75 percent of patients who complete treatment show s i g n i f i c a n t improvements, which are maintained for four to nine years. However, the same reviews have 114 also noted that due to the nature of the exposure treatments, up to 30 percent of p a t i e n t s refuse or f a i l to complete treatment. Alternative behavioral psychotherapy techniques offer treatment options which might prove more palatable to patients; James, Hampton, and Larsen (1983) compared the efficacy of imaginal and i n vivo desensitization techniques i n the treatment of agoraphobics and found the two procedures to be equally e f f e c t i v e . Likewise, Williams, Turner, and Peer (1985) compared i n vivo exposure with a c o g n i t i v e behavior psychotherapy technique (guided mastery training) and found the l a t t e r to be more effec t i v e than the former i n the treatment of height phobics. Turning to a consideration of pharmacotherapy treatment, there are some adherents of the use of anti-anxiety medications (Marks, J . , 1985); however, there are other researchers who maintain that while anti-anxiety medications may have short-term p a l l i a t i v e value i n reducing anxiety, t h e i r long-term value should remain i n question because phobic symptoms have been observed to return when medication i s discontinued (Marks, I.; 1983). With regard to combined psy chotherapy\/pharmacotherapy treatments, the opinions of researchers are again mixed. Z i n t r i n , K l e i n , and Woerner (1980) assigned 76 female agoraphobic patients to a combined imipramine and i n vivo exposure condition or to a combined placebo and i n vivo exposure treatment condition; they found that the imipramine condition was s i g n i f i c a n t l y more effec t i v e than the placebo condition. S i m i l a r l y , Mavissakalian, Michelson, and Dealy (1983) treated 18 agoraphobic patients with imipramine or imipramine plus i n vivo exposure; they also found s i g n i f i c a n t l y greater improvement on phobic measures i n the imipramine plus i n vivo exposure condition. On the other hand, Marks, Gray, Cohen, H i l l , Mawson, Ramm, and Stern (1983) assigned 45 agoraphobic patients to either an i n vivo exposure or a relaxation condition and these two conditions were then combined with either an imipramine or a 115 placebo condition. The investigators found that patients i n the i n vivo exposure condition improved s i g n i f i c a n t l y and maintained t h e i r gains at a one-year follow-up but that imipramine did not enhance the effectiveness of the exposure condition r e l a t i v e to the placebo condition. At a two-year follow-up of the same patients, Cohen, Monteiro, and Marks, (1984) found that about two-thirds of the patients who had improved remained improved but that there were now no s i g n i f i c a n t differences between any of the four treatment conditions. With regard to the treatment of the su b c l a s s i f i c a t i o n of Obsessive-Compulsive Disorders, the majority of outcome st u d i e s have focussed on psychotherapy treatment alone or combined psychotherapy\/pharmacotherapy treatment. Results indicate that psychotherapy i s ef f e c t i v e i n t r e a t i n g p a t i e n t s w i t h o b s e s s i v e r i t u a l s and t h a t combined psychotherapy\/ pharmacotherapy may be helpf u l i n tr e a t i n g patients with ruminative thoughts or patients who have also been diagnosed with Depressive Disorder. Marks, Hodgson, and Rachman (1975) compared the effectiveness of i n vivo exposure wit h muscular r e l a x a t i o n i n the treatment of 20 patients with chronic obsessive-compulsive r i t u a l s ; p atients i n the i n v i v o c o n d i t i o n showed s i g n i f i c a n t improvement after three weeks and maintained improvement at a three-year follow-up while patients i n the relaxation condition showed no improvement. In a review of 14 studies comparing the effectiveness of i n vivo exposure and relaxation treatment, Marks (1981) found the former treatment to be consistently more effec t i v e than the l a t t e r . Moving to st u d i e s of combined psychotherapy\/pharmacotherapy, the opinions of investigators are mixed as to whether pharmacotherapy has an additive effect when combined with psychotherapy treatment. Amin, Ban, Pecknold, and Klingner (1977) assigned s i x patients with obsessive-compulsive neurosis to either a clomipramine plus behavior therapy, clomipramine plus 116 simulated behavior therapy, or placebo plus behavior therapy c o n d i t i o n ; p a t i e n t s i n the clomipramine plus behavior therapy condition showed the greatest improvement. Solyom and Sookman ( 1977) assigned 23 obsessive-compulsive patients to either a clomipramine, i n vivo exposure, or response prevention treatment condition. The investigators found that clomipramine was as e f f e c t i v e as i n v i v o exposure and more effective than response prevention i n reducing ruminative thoughts but clomipramine was l e s s ef f e c t i v e than i n vivo exposure i n reducing r i t u a l i s t i c behaviors. Marks, Stern, Mawson, Cobb, and McDonald (1980) t r e a t e d obsessive-compulsive patients using either an i n vivo exposure or a relaxation condition combined with either a clomipramine or placebo condition; r e s u l t s i n d i c a t e d that clomipramine was effective i n reducing depressive symptoms i n those patients who were s i g n i f i c a n t l y depressed at the s t a r t of treatment, however i t had no effect by i t s e l f on obsessive behaviors i n nondepressed patients and did not produce an additive effect when combined with i n vivo exposure or relaxation. Returning to the Marks (1981) review, the author summarizes the l i t e r a t u r e on the r e l a t i v e effectiveness of psychotherapy and combined psychotherapy\/pharmacotherapy with the conclusion that patients exhibiting obsessive r i t u a l i z e d behavior appear to be most responsive to i n v i v o exposure and that patients exhibiting obsessive ruminative thoughts appear to be most responsive to combined psychotherapy\/pharmacotherapy. B r i e f l y reviewing the treatment of the sub-classifications of Anxiety States and Neurotic Depression, a number of studies of the treatment of Anxiety States indicate that pharmacotherapy i s more effective than placebo (e.g., Fyro, Beck-Friis, & Sjostrand, 1974; Goldberg & F i n n e r t y , 1979; Pinosky, 1978) and that relaxation psychotherapy may be as effective as a n t i -anxiety medication i n reducing self-reported anxiety i n patients with panic d i s o r d e r s (Taylor, Kenigsberg, & Robinson, 1982). With regard to the 117 treatment of Neurotic Depression, the l i t e r a t u r e reviewed i n the preceding s e c t i o n on the treatment of Depressive Disorder may apply as well to judgments about the effectiveness of psychotherapy, pharmacotherapy, and combined psychotherapy\/pharmacotherapy i n the treatment of Neurotic Depression as most studies do not e x p l i c i t l y d i f f e r e n t i a t e between the two dis o r d e r s i n s p e c i f y i n g t h e i r patient population. Penfold, a feminist p s y c h i a t r i s t p r a c t i c i n g i n Vancouver, B.C., makes a strong theoretical and e m p i r i c a l case for the use of psychotherapy over pharmacotherapy i n the treatment of neurotic depression(Penfold and Walker, 1983). She argues that since most of the patients who are diagnosed with the disorder are women i n d i f f i c u l t l i f e circumstances, teaching these women how to cope with or change t h e i r situations should be more effective i n producing long-term symptom improvement than treatment with anti-anxiety or anti-depressant medications. As i n the case of Depressive Disorder, i n the treatment of Neurotic Disorders psychotherapy, pharmacotherapy, and combined psychotherapy\/ pharmacotherapy each appear to be more effective than placebo conditions although the results of outcome studies produce mixed r e s u l t s f o r some treatment modes w i t h i n p a r t i c u l a r sub-classifications. With regard to management mode, patients diagnosed with Neurotic Disorders are t y p i c a l l y treated i n an outpatient se t t i n g , usually by a single therapist. Based on th i s pattern of treatment practices, I would suggest that simple substitution p o s s i b i l i t i e s for Diagnostic Code 300 be considered to f a l l i n the moderate range. Organic Psychotic Conditions (Diagnostic Codes: 290-294) and Other Psychoses (Diagnostic Codes: 295-299) Organic Psychotic Conditions and Other Psychoses are t y p i c a l l y treated i n the combined psychotherapy\/pharmacotherapy treatment mode and i n the 118 therapy team management mode, either i n an outpatient setting, an inpatient psych i a t r i c setting, or a chronic care setting. In those instances where a patient might sometimes be s u c c e s s f u l l y managed by a s i n g l e t h e r a p i s t (Diagnostic Codes: 295-299), because the preference i s for the combined psychotherapy\/pharmacotherapy treatment mode, the s i n g l e t h e r a p i s t would necessarily need to be a p s y c h i a t r i s t . Based on t h i s pattern of treatment practices, I would suggest that simple s u b s t i t u t i o n p o s s i b i l i t i e s f o r Diagnostic Codes 290-294 and 295-299 be considered to f a l l i n the low range. The diagnostic c l a s s i f i c a t i o n Organic Psychotic Conditions refers to a group of disorders which includes Senile and Presenile Organic Psychoses (Diagnostic Code: 290), Alcoholic Psychoses (Diagnostic Code: 291), Drug Psychoses (Diagnostic Code: 292), Transient Psychoses (Diagnostic Code: 293), and Other Organic Psychoses (Diagnostic Code: 294). Patients suffering from the f i r s t three conditions are t y p i c a l l y treated i n an inpatient setting during the acute phase of the disorder and then maintained i n a chronic care s e t t i n g when the disorder i s i n remission. For patients with Transient Psychoses, which are usually caused by some t o x i c , infectious, metabolic, or systemic disturbance, the patient i s often released from the inpatient s e t t i n g without the need for further care. Patients suffering from Other Organic Psychoses, which are usually caused by organic brain damage due to alcohol abuse, Huntington's Chorea, or s i m i l a r d i s o r d e r s , are u s u a l l y released either to an outpatient setting or a chronic care setting depending on the degree of impairment. Other Psychoses r e f e r s t o a group of di s o r d e r s which i n c l u d e s Schizophrenic Psychoses (Diagnostic Code: 295), A f f e c t i v e Psychoses (Diagnostic Code: 296), Paranoid States (Diagnostic Code: 297), Other Nonorganic Psychoses (Diagnostic Code: 298), and Psychoses with O r i g i n Specific to Childhood (Diagnostic Code: 299). As noted above, patients are 119 t y p i c a l l y treated by a therapy team i n an inpatient p s y c h i a t r i c s e t t i n g during the acute phase of the disorder and are then maintained either i n an outpatient setting or a chronic care setting during remission. Patients are t y p i c a l l y t r e a t e d with combined psychotherapy\/pharmacotherapy, with the exception of some patients diagnosed with Paranoid States who are sometimes able to function adequately without medication ( R i t z i e r , 1981). For the Schizophrenic Disorders, an extraordinary amount of research has been devoted to the effectiveness of both the pharmacotherapy (Menuck & Seeman, 1985) and the psychotherapy modes of treatment, including token economies, m i l i e u therapy, and family therapy (Brady, 1984; Falloon, 1986; Goldstein & Doane, 1982; Jacobs, Donahoe, & Falloon, 1985; Kazdin, 1982; Kirshner & Johnston, 1982; L e f f , Kuipers, Berkowitz, & Sturgeon, 1985; Paul & Lentz, 1977; Platman, 1983; and Schooler, 1986). Other Nonorganic Psychoses are usually attributed to a recent traumatic l i f e experience; i n remission the patient may either be released without the need for further care or be treated by a therapy team i n an outpatient setting. Psychoses with Origin Specific to Childhood refers to an exceedingly large range of disorders, which includes the s u b - c l a s s i f i c a t i o n s of I n f a n t i l e Autism, Organic Brain Disease, and Childhood Schizophrenia; during remission patients are t y p i c a l l y released to an outpatient or chronic care setting and managed by a therapy team or a single therapist i n consultation with a team of non-mental health workers (Brady, 1984; Dudziak, 1982; Hung, 1977). Personality Disorders (Diagnostic Code; 301) and Other Nonpsychotic Mental Disorders (Diagnostic Codes: 302-316) In considering the relationship between patterns of treatment practice and p o s s i b i l i t i e s for simple substitution for these mental disorders, I would suggest the disorders f a l l into two groups, those i n the moderate range and 120 those i n the high range. I w i l l begin with a discussion of those disorders which appear to f a l l i n the moderate range and then move to a discussion of those disorders which appear to f a l l i n the high range. In the moderate range, three disorders with s i m i l a r treatment patterns are Alcohol Dependence (Diagnostic Code: 303), Drug Dependence (Diagnostic Code: 304), and Nondependent Drug Abuse (Diagnostic Code: 305). Patients diagnosed with Alcohol Dependence are sometimes i n i t i a l l y t r e a t e d i n an inpatient s e t t i n g for d e t o x i f i c a t i o n ; some researchers have found that as an aid to the medical interventions used i n d e t o x i f i c a t i o n , psychotherapy (supportive counselling) treatment and pharmacotherapy treatment are equally e f f e c t i v e (Frecker, Shaw, Zilm, Jacob, S e l l e r s , & Degani, 1982; S a l e t u , Saletu, Grunberger, Mader, & Karobath, 1983). Patients may then continue either i n an inpatient or an outpatient treatment setting; reviews of studies comparing the efficacy of inpatient and outpatient treatment indicate that with the exception of deteriorated patients who have no permanent home, outpatient treatment i s as effec t i v e as inpatient treatment ( M i l l e r & Hester, 1986). In the inpatient s e t t i n g , management mode may be either a therapy team or a single therapist; i n the outpatient s e t t i n g , patients are t y p i c a l l y treated by a single therapist alone or a single therapist i n association with a team of non-mental h e a l t h workers. For the majority of patients psychotherapy i s the treatment mode employed, which includes behavior modification, cognitive behavior, and family therapies (Brandsma & Pattison, 1985; Kaufman & Pattison, 1981; Litman & Topham, 1983; Orford, 1984; Sobell & Sobell, 1983; Wiens & Menustik, 1983); as w e l l , a minority of patients are maintained with pharmacotherapy or combined psychotherapy\/ pharmacotherapy using medications which block the metabolism of alcohol (Litman & Topham, 1983). 121 For p a t i e n t s diagnosed with Drug Dependence, patterns of treatment practice are sim i l a r to those for patients with Alcohol Dependence with the proviso that after the i n i t i a l d e t o x i f i c a t i o n phase, patients addicted to opioids, whether obtained through prescription or i l l e g a l l y , frequently are maintained through pharmacotherapy or combined psychotherapy\/pharmacotherapy with synthetic opiate medications. Pharmacotherapy treatment wi t h a n t i -anxiety or anti-depressant medications has not been found to be eff e c t i v e i n increasing the l e v e l of c l i e n t f u n c t i o n i n g . Again, treatment mode i s t y p i c a l l y a single therapist i n association with a team of non-mental health workers (Gawin & Kleber, 1984; Gossop, Bradley, Stang, & Connell, 1984; Rounsaville & Kleber, 1985; Rush & Shaw, 1981; Tennant & Rawson, 1982). For patients diagnosed with Nondependent Drug Abuse, psychotherapy i s t y p i c a l l y the treatment mode and single therapist the management mode, sometimes i n association with a team of non-mental health workers (Harrup, Hansen, & Soghikian, 1979; Holroyd, 1980). The remaining mental disorders which f a l l i n t o the moderate range of simple substitution p o s s i b i l i t i e s have a heterogeneous pattern of treatment p r a c t i c e s with the common denominator being that treatment practices may sometimes i n v o l v e the pharmacotherapy or combined p s y c h o t h e r a p y \/ pharmacotherapy treatment modes as well as the psychotherapy treatment mode and the therapy team as well as the single therapist management mode. Patients diagnosed with Somatoform Disorders (Diagnostic Code: 306) t y p i c a l l y present with recurrent multiple somatic complaints or symptoms suggesting neurological disease which have no basis i n a physical disease process. Although the treatment mode i s usually psychotherapy and the management mode single therapist, I have suggested that treatment practices for t h i s mental disorder f a l l i n the moderate rather than the high range because of the possible need for a d i f f e r e n t i a l medical\/psychiatric diagnosis 122 (Knesper, Pagnucco\/ & Wheeler, 1985) and because patients frequently drop out of psychotherapy to pursue medical interventions (Goodwin & Guze, 1984). Special Symptoms NEC (Diagnostic Code: 307) i s a category of mental disorder which contains a number of su b - c l a s s i f i c a t i o n s , including Anorexia, Bulimia, Enuresis, Stuttering, and Tics. In the treatment of Anorexia and B u l i m i a , p a t i e n t s are t y p i c a l l y treated either i n an inpatient hospital s e t t i n g or an outpatient s e t t i n g by a single therapist i n association with a team of non-mental h e a l t h workers. Reviews of studies comparing the effectiveness of psychotherapy, pharmacotherapy, and combined psychotherapy\/ pharmacotherapy indicate that psychotherapy i s r e l a t i v e l y more effec t i v e (Elston & Thomas, 1985; Halmi, 1982, 1983a, 1983b; Herzog & Copeland, 1985; Huon & Brown, 1984), but because there are adherents to the l a t t e r two treatment modes I have considered treatment practices for the disorders to be i n the moderate range of simple substitution p o s s i b i l i t i e s . In the treatment of Enuresis, patients are t y p i c a l l y treated as o u t p a t i e n t s by a s i n g l e therapist and behavior modification psychotherapy techniques have been found t o be more e f f e c t i v e than e i t h e r pharmacotherapy or c o m b i n e d psychotherapy\/pharmacotherapy (Mikkelsen & Rapoport, 1980; Netley, Khanna, McKendry, & Lovering, 1984; Wagner, Johnson, Walker, Carter, & Wittner, 1982; W i l l e , 1986). In the treatment of S t u t t e r i n g , treatment by a speech therapist has been found to be more effec t i v e than pharmacotherapy (Rustin, Kuhr, Cook, & James, 1981). In the treatment of Tics, patients suffering from G i l l e s De La Tourette Syndrome are t y p i c a l l y t r e a t e d by a s i n g l e t h e r a p i s t w i t h the p r e f e r r e d t r e a t m e n t t e c h n i q u e s b e i n g e i t h e r pharmacotherapy or combined psychotherapy\/pharmacotherapy ( S u r w i l l o , Mohammad, & B a r r e t t , 1978; Thomas, Abrams, & Johnson, 1971), however, behavior modification psychotherapy techniques have been used i n patients who cannot tolerate medication (Tophoff, 1973). Other forms of t i c s are usually 123 treated with behavior modification psychotherapy techniques (Knepler & Sewall, 1974; Schulman, 1974). Patients diagnosed with Acute Reaction to Stress (Diagnostic Code: 308) have been subject to a traumatic event\/ such as rape, m i l i t a r y combat, natural disaster, or catastrophic accident, and have subsequently developed ch a r a c t e r i s t i c symptoms which involve reexperiencing the traumatic event, psychic numbing, and a v a r i e t y of autonomic, dysphoric, or cognitive complaints. Depending upon the phase of the disorder, treatment may be i n an i n p a t i e n t or outpatient s e t t i n g and may employ either the psychotherapy, pharmacotherapy, or combined psychotherapy\/pharmacotherapy treatment modes and the single therapist or therapy team management modes. Patients diagnosed with S p e c i f i c Nonpsychotic Disorders F o l l o w i n g Organic B r a i n Damage (Diagnostic Code: 310) show changes i n behavior following damage to the f r o n t a l areas of the brain; there i s a diminution of s e l f - c o n t r o l , foresight, c r e a t i v i t y , and concentration, and frequently, but not necessarily, a deterioration i n i n t e l l e c t or memory. In the i n i t i a l phase of the disorder a n t i - c o n v u l s a n t medication may be used as a prophylactic measure to decrease brain function and thus reduce the patient's experience of the symptoms. In subsequent phases, medication i s usually discontinued and the patient involved i n a r e h a b i l i t a t i o n psychotherapy program. The patient may be treated i n an inpatient or outpatient setting depending upon the phase of the disorder and treatment i s t y p i c a l l y by a single therapist i n association with a team of non-mental health workers ( D i l l e r & Gordon, 1981; Grimm & Bleiberg, 1986; Kreutzer & Morrison, 1986). Disturbance of Emotions Specific to Childhood\/Adolescence (Diagnostic Code: 313) i s an exceptionally broad diagnostic category, i n d i c a t i v e of the circumstance that diagnostic systems are less well-developed for children than for adults. Given the d i v e r s i t y of the sub-classifications included 124 within t h i s disorder, a l l of the treatment and management modes are used. Since reviews of s t u d i e s of the treatment of emotional disturbances i n children indicate that the psychotherapy treatment mode and the s i n g l e t h e r a p i s t management mode i s one of the patterns of treatment practice employed for t h i s disorder (Casey & Berman, 1985; Michelson, Mannarino, Marchione, Stern, Figueroa, & Beck, 1983; Millman, Schaefer, & Cohen, 1980; P e l l i g r i n i & Urbain, 1985; Stein & Davis, 1982), I have suggested that simple substitution p o s s i b i l i t i e s for t h i s disorder be considered to f a l l i n the moderate range. H y p e r k i n e t i c Syndrome of Childhood (Diagnostic Code: 314) i s an extremely controversial diagnostic category both with regard to the proper parameters for diagnosis and with regard to the most effective method of treatment. There i s debate as to whether hyperactivity i s a true syndrome because no s i n g l e symptom or group of symptoms has been i d e n t i f i e d as diagnostic (Loney, 1980; Ross & Ross, 1982) and because s t u d i e s of the r e l i a b i l i t y of diagnosis indicate that c l i n i c i a n s may variously diagnose children with hyperactive behavior as Hyperactive Syndrome, Conduct Disorder, Emotional Disturbance, or Learning Disabled (Cannon & Comptom, 1980; Shapiro & Sherman, 1983; Wender, 1983). Treatment i s usually i n the single therapist management mode, either alone or i n association with a team of non-mental h e a l t h workers. Reviews of studies comparing the e f f e c t i v e n e s s of psychotherapy and pharmacotherapy have found psychotherapy to be equally or more ef f e c t i v e than pharmacotherapy (Firestone, K e l l y , Goodman, & Davey, 1981); however, as pharmacotherapy has a firm position i n the pattern of treatment p r a c t i c e s , I have suggested that Hyperkinetic Syndrome be c o n s i d e r e d t o f a l l i n the moderate range of simple s u b s t i t u t i o n p o s s i b i l i t i e s . 125 Psychosomatic Disorders (Diagnostic Code: 316) refer to conditions i n which psychological factors contribute to the i n i t i a t i o n or exacerbation of a physical condition. Common examples of physical conditions for which t h i s category may be appropriate include asthma, obesity, migraine headache, and gastric ulcer. Patients may be treated i n inpatient hospital settings or outpatient settings, usually by a single therapist. Reviews of studies of psychotherapy treatment, p a r t i c u l a r l y the techniques of behavioral medicine such as biofeedback, relaxation, deconditioning, assertiveness t r a i n i n g , and i n t e r v e n t i o n t o increase adherence to medical procedures, i n d i c a t e psychotherapy i s an effec t i v e treatment for a number of sub-classifications of the disorder (Agras, 1982; Blanchard, 1982; Conners, 1983; Pomerlau, 1982). As i n the case of Somatoform Disorders, although the treatment mode i s usually psychotherapy and the management mode single therapist, I have suggested that treatment practices for t h i s mental disorder be considered to f a l l i n the moderate rather than the high range because of the possible need for a d i f f e r e n t i a l medical\/psychiatric diagnosis (Knesper et a l . , 1985) and because p a t i e n t s may p r e f e r to pursue pharmacotherapy treatment and\/or additional medical interventions. To the high range of simple substitution p o s s i b i l i t i e s , I have assigned f i v e disorders which are t y p i c a l l y treated i n the psychotherapy treatment mode and the single therapist management mode: Personality Disorders, Sexual Disorders, Adjustment Reaction, Conduct Disorder NEC and Specific Delays i n Development. Psychotherapy treatments include behavioral and cognitive behavioral techniques and also verbal techniques, such as the dynamic, su p p o r t i v e , transactional, gestalt, and r a t i o n a l emotive psychotherapies. Personality Disorders (Diagnostic Code: 301) are considered d i f f i c u l t to trea t ; the o r i g i n of the disorders i s conceptualized to be a coping strategy developed i n childhood to deal with an emotionally inadequate developmental 126 environment, hence, the patient i s often very well-defended and tends to become exceedingly anxious when attempting to address the problem. However, i f the therapist i s successful i n gaining the patient's t r u s t , any of several psychotherapy techniques have proved e f f e c t i v e (Buie & A d l e r , 1982, Masterson, 1981; Numberg, 1984; Spitz, 1984). Sexual Disorders (Diagnostic Code: 302) includes a number of sub-c l a s s i f i c a t i o n s for which psychotherapy treatment has proved the p r i n c i p a l treatment mode but whose effectiveness varies with the p a r t i c u l a r sub-c l a s s i f i c a t i o n . For Pedophilia, neither psychotherapy nor pharmacotherapy has been found to be an e f f e c t i v e treatment. In the case of Incest Offenders, i f the p a t i e n t has not offended o u t s i d e h i s \/ h e r home, psychotherapy treatment, which usually includes behavior modification and cognitive behavior psychotherapy techniques and parenting s k i l l s , has brought improvement. In the treatment of Impotence and F r i g i d i t y , behavior modification and cognitive behavior psychotherapy techniques, usually grouped under the rubric of sex therapy, have been found to be effe c t i v e (Cooper, 1981; Kuriansky & Sharpe, 1981; Marks, 1981), and while there has been some research into the use of testosterone with Impotence, t h i s has not been found to be an e f f e c t i v e treatment (Cooper, 1981). In the treatment of Transvestism, Exhibitionism, and Sex Offenders, the usual treatment mode i s behavior modification and cognitive behavior techniques; very ra r e l y , i n the case of the v i o l e n t r a p i s t who has proved unresponsive to a l l other interventions, the medication provera may be used. Adjustment Reaction (Diagnostic Code: 309) refers to a maladaptive r e a c t i o n to an i d e n t i f i a b l e p s y c h o s o c i a l s t r e s s o r such as d i v o r c e , bereavement, retirement, or f i n a n c i a l loss. With these patients, t y p i c a l l y the treatment strategy i s the use of supportive psychotherapy to a s s i s t the patient to cope u n t i l the stressor remits or the use of cognitive behavior 127 psychotherapy or the verbal psychotherapies to a s s i s t the patient to a t t a i n a new l e v e l of adaptation i f the stressor persists-Patients diagnosed with Conduct Disorder NEC (Diagnostic Code: 312) are c o n s i d e r e d d i f f i c u l t t o m o t i v a t e f o r p a r t i c i p a t i o n i n the v e r b a l psychotherapies (Ranieri, 1984). Much research has focussed on the probable causes of the disorder i n an attempt to develop an e f f e c t i v e treatment (Anolik, 1983; Lane, 1980; Loeber, 1982; Loeber & Dishion, 1983; Paperny & Deisher, 1983; R i c h , 1982) and while a number of theories have been suggested, ranging from the b i o l o g i c a l to the psychosocial, there has been much discouragement with the lack of effectiveness of the psychotherapy and pharmacotherapy treatments which have been attempted (Clarke, 1984). However, i n an extensive review of treatment programs which have been implemented with t h i s patient population, Ross and Fabiano (1985) report that cognitive behavior psychotherapy techniques have proved the most ef f e c t i v e i n bringing improvement. S p e c i f i c Delays i n Development (Diagnostic Code: 315) refers to d e f i c i t s such as dyslexia, dyscalculia, or language disorders i n an otherwise normal i n d i v i d u a l and are much more frequently diagnosed i n children than i n adults because that i s the stage of development at which the effects of the d i s o r d e r on academic f u n c t i o n i n g f i r s t become apparent. Typically the therapist treats the patient i n association with a team of non-mental health workers, such as teachers and family members, a s s i s t i n g with diagnosis and with the s o c i a l manifestations of the disorder. The usual treatment mode i s behavior modification and cognitive behavior psychotherapy techniques and remedial education (Cannon & Compton, 1980; Millman, Schaefer, & Cohen, 1980; Wender, 1983). 128 Mental Retardation (Diagnostic Codes: 317-319) The diagnostic c l a s s i f i c a t i o n of Mental Retardation i n c l u d e s three disorders: Mild Mental Retardation (Diagnostic Code: 317), Other Specified Retardation (Diagnostic Code: 318), and Unspecified Mental Retardation (Diagnostic Code: 319). Patients diagnosed with Mild Mental Retardation t y p i c a l l y l i v e i n the community, either with t h e i r families or i n a chronic care s e t t i n g . Behavior m o d i f i c a t i o n and s k i l l t r a i n i n g psychotherapy techniques are usually the treatment mode employed. Patients are rarely t r e a t e d i n s p e c i a l i z e d i n p a t i e n t settings for the retarded unless they exhibit disruptive behaviors, f r e q u e n t l y u n r e l a t e d to the r e t a r d a t i o n condition, which cannot be managed i n the usual f a c i l i t i e s for such problem behaviors, such as the j u d i c i a l system or inpatient psychiatric settings. Patients are t y p i c a l l y managed by a single therapist acting as consultant to non-mental health workers or family members. For patients diagnosed with Other S p e c i f i e d Retardation, which refers to the sub-classifications of Moderate, Severe, and Profound Retardation, the goal of inpatient treatment, for those patients who do not require intensive nursing care or who do not have intractable behavior problems, i s placement i n a chronic care setting. The preferred treatment mode i s behavior modification and s k i l l t r a i n i n g psychotherapy techniques; there i s an attempt to avoid the use of pharmacotherapy as a \"chemical straight jacket\" and combined psychotherapy\/ pharmacotherapy i s t y p i c a l l y employed only after psychotherapy has proved i n e f f e c t i v e or when the p a t i e n t a l s o s u f f e r s from psychosis. In the inpatient s e t t i n g , patients are t y p i c a l l y managed by a therapy team and i n the outpatient setting by a single therapist acting as consultant to a team of non-mental h e a l t h workers. With regard t o p a t i e n t s diagnosed as Unspecified Mental Retardation, i t i s d i f f i c u l t to make statements about the treatment and management modes employed i n these instances because the 129 category i s indeterminate, but I would suggest that the same patterns of treatment practice hold for t h i s diagnostic c l a s s i f i c a t i o n as for Mild Mental Retardation and Other Specified Retardation (Hornby & Singh, 1983; Kazdin & Matson, 1981; Matson & Gorman-Smith, 1986). In summary, when these disorders are treated i n an inpatient s e t t i n g , psychotherapy or combined psychotherapy\/pharmacotherapy are t y p i c a l l y the treatment modes and therapy team the management mode employed. When these disorders are treated i n an outpatient s e t t i n g , psychotherapy and single therapist are t y p i c a l l y the treatment and management modes employed, with the therapist acting as a consultant to a team of non-mental health workers. Based on t h i s pattern of treatment practices, I would suggest that the simple substitution p o s s i b i l i t i e s for Diagnostic Codes 317-319 be considered to f a l l i n the moderate range. Conditions Not Attributable to a Mental Disorder Diagnostic Codes: (V61-V71) For the disorders i n t h i s c l a s s i f i c a t i o n , I have suggested that two disorders be considered to f a l l i n the high range of simple substitution p o s s i b i l i t i e s and that the remainder be considered to f a l l i n the low range of simple substitution p o s s i b i l i t i e s . Those disorders i n the low range either are indeterminate (thus not permitting an estimate of substitution p o s s i b i l i t i e s without further study) or involve medical procedures. As i t i s not possible to make statements about treatment mode and management mode for these categories, I have omitted t h e i r i n d ication i n the summary i n Table VIII. The diagnostic codes I have suggested be assigned to th i s group are as follows: No Medical F a c i l i t y for Care (Diagnostic Code: V63), Procedures Not Done (Diagnostic Code: V64), Other Reasons for Consultation (Diagnostic Code: V65), Convalescence (Diagnostic Code: V66), Follow-up Examination (Diagnostic Code: V67), Administrative Encounter Diagnostic Code: V68), 130 General Medical Examination (Diagnostic Code: V70), and Observation of Suspected Condition (Diagnostic Code: V71). As Diagnostic Codes V63-V71 accounted f o r only some $3,000 of the approximately $7.5 m i l l i o n i n expenditures for private practice psychiatry services (considerably less than .01 percent) i n the data analyzed i n the present study, I have excluded them from consideration. The two disorders which I have suggested be assigned to the high range are Other Family Circumstances (Diagnostic Code: V61) and Other Psychosocial Circumstances (Diagnostic Code: V62). These conditions are treated i n the same manner as the other disorders i n the high range, t y p i c a l l y i n the psychotherapy treatment mode and the single therapist management mode- Other Family Circumstances refers to a range of si t u a t i o n s , including parent-child c o n f l i c t , divorce, incest, bereavement, and family violence; likewise, Other Psychosocial Circumstances also refers to a range of s i t u a t i o n s , which, although not r e s u l t i n g i n a mental disorder, produce considerable suffering and disl o c a t i o n for the i n d i v i d u a l and his\/her associates. Psychotherapy treatments can be delivered i n an i n d i v i d u a l , group, or family context and include behavior modification and cognitive behavior techniques as well as the verbal techniques (Adler & Raphael, 1983; Dulcan, 1984; Holmes, 1985; Jacobs, 1982; J e l l i n e k & Slovik, 1981; O'Shea & Phelps, 1985; Schwartzberg, 1981; S i l v e r , Lubin, M i l l e r , & Dobson, 1981; Spitz, 1984; Swanson & Biaggio, 1985; Wahler, & Fox, 1981). To conclude, i n Chapters One through Seven I have attempted to set the stage for the development of both q u a l i t a t i v e and quantitative answers to the three questions the present study i s designed to investigate: 1. Which services present the p o s s i b i l i t y for substitution? 2. What would be the projected cost implications of implementing such substitutions? 1 31 3. What licensure and market r i g i d i t i e s would need to be changed for implementation? In F i g u r e 2, I have proposed a model of mental h e a l t h manpower a l l o c a t i o n , asserting that a pool of mental health manpower exi s t s which hol d s some s k i l l s and services i n common and which therefore o f f e r s the p o s s i b i l i t y of simple s u b s t i t u t i o n i n s e r v i c i n g mental health needs. I have presented a review of l i t e r a t u r e and documents which indicates that a l l four core mental health professions are trained (Tables I - V) and authorized (Tables VI and VII) to provide psychotherapy services, that psychotherapy i s an e f f e c t i v e treatment f o r a number of mental disorders, and that the four professions can provide comparable psychotherapy services within a comparable time period. As well, I have discussed the p r a c t i c e p r i v i l e g e constraints which l i m i t the a b i l i t y of non-medical mental health p r a c t i t i o n e r s to provide psychotherapy services i n some settings (Table V I I ) . F i n a l l y , from an examination of patterns of treatment p r a c t i c e , I have suggested that a l e v e l of simple s u b s t i t u t i o n p o s s i b i l i t i e s (\"low,\" \"moderate,\" \"high\") can be assigned to each of the mental disorder diagnostic codes i n the ICD-9-CM c l a s s i f i c a t i o n system (Table V I I I ) . In summarizing the ra t i o n a l e for the present i n v e s t i g a t i o n of possible economies to be derived from manpower s u b s t i t u t i o n i n mental health service d e l i v e r y , I would l i k e at t h i s point to return to the model g r a p h i c a l l y represented i n Figures 3a and 3b. As Figure 3b i l l u s t r a t e s , the greatest economies should r e s u l t under conditions where the majority of service expenditures are for the treatment of mental disorders i n diagnostic codes with moderate to high treatment s u b s t i t u t a b i l i t y (Axis I) and for t a r i f f items with low p r a c t i c e p r i v i l e g e constraints (Axis I I ) , and where the payment rate of the pro f e s s i o n a l group proposed for s u b s t i t u t i o n represents a s i g n i f i c a n t saving over current personnel costs (Axis I I I ) . Thus, i f , i n 1 32 examining the b i l l i n g data for fee-for-service psychiatry practice, we find that the m a j o r i t y of service expenditures f a l l i n the areas of highest treatment s u b s t i t u t a b i l i t y and lowest practice p r i v i l e g e constraints, and i f the r e l a t i v e payment rates are advantageous, then there are r e l a t i v e l y more economies to be gained from pursuing the implementation of manpower substitution. Axes I and I I , when taken together, permit an estimate of potential for manpower substitution, or, i n other words, the s u b s t i t u t a b l e share of services and costs. As i l l u s t r a t e d i n Figure 3a, i f we consider the extreme cases of possible conditions for manpower substitution, that i s , the four corners of the diagram, we can see that the upper left-hand corner represents a s i t u a t i o n where there i s v i r t u a l l y no potential for economies from manpower s u b s t i t u t i o n because l i t t l e or no p o s s i b i l i t y for treatment substitution exists and practice p r i v i l e g e constraints severely r e s t r i c t service delivery by a l t e r n a t e professionals. An example where both such educational and regulatory barriers arise occurs i n the position of psychiatrists as the only mental health profession q u a l i f i e d to prescribe medication. In the case of the upper right-hand corner, again, there i s l i t t l e potential for manpower s u b s t i t u t i o n because, although there may be considerable treatment s u b s t i t u t a b i l i t y , practice p r i v i l e g e constraints s t i l l p r o h i b i t manpower s u b s t i t u t i o n . Thus, for example, while the training of a l l four mental health professions permits them to provide a range of services i n hospital settings, p s y c h i a t r i s t s are the only group which has been granted c l i n i c a l hospital p r i v i l e g e s . S i m i l a r l y , i n the lower left-hand corner, the reverse condition occurs, i n which practice p r i v i l e g e constraints do not r e s t r i c t service delivery but potential for manpower substitution ,is low because there are few services for which treatment s u b s t i t u t a b i l i t y i s possible. Such a sit u a t i o n occurs i n the case of int e l l i g e n c e testing for, while there are no 133 legal prohibitions against other professions a d m i n i s t e r i n g these t e s t s , psychologist are the only professional group trained to provide t h i s service. The lower right-hand corner i l l u s t r a t e s the case of maximum potential for manpower substitution because treatment substitution p o s s i b i l i t i e s are high and service delivery i s not affected by practice p r i v i l e g e constraints. When Axis I I I i s added to the model, as i l l u s t r a t e d i n Figure 3b, potential economies for such manpower substitution can be projected. Thus, once again, the upper rear left-hand corner of the diagram indicates no potential for economies from manpower substitution because not only are the p o s s i b i l i t i e s for manpower substitution exceedingly low, but the costs of replacement personnel equal those of existing personnel. Likewise, the lower f r o n t right-hand corner i l l u s t r a t e s the case of maximum potential for economies from manpower s u b s t i t u t i o n f o r i t i s at t h i s p o i n t i n the convergence of the three controlling variables that the p o s s i b i l i t i e s for manpower substitution and the r e l a t i v e savings i n personnel costs are greatest. Thus, the potential for economies from manpower substitution increases i n somewhat of a fan-shape as we proceed from the upper rear left-hand corner to the lower front right-hand corner of Figure 3b. However, even i n the most extreme case of maximum potential for economies from manpower substitution, there are factors which might l i m i t the f e a s i b i l i t y of manpower substitution, for example, whether substitutable services are judged to be valuable or t r i v i a l , whether s u b s t i t u t i o n of services i s judged to be p r a c t i c a l or impractical and whether the cost savings from manpower s u b s t i t u t i o n are judged to be of s u f f i c i e n t magnitude to warrant i n s t i t u t i n g changes i n the service delivery system. The remaining chapters w i l l attempt to provide q u a n t i t a t i v e estimates of the p o t e n t i a l f o r economies from manpower substitution under various conditions of treatment s u b s t i t u t a b i l i t y , practice 1 34 p r i v i l e g e constraints, and r e l a t i v e payment rates, and to discuss q u a l i t a t i v e issues which might affect the potential for manpower economies from such substitution i n mental health service delivery. 135 CHAPTER EIGHT METHODOLOGY Met h o d o l o g i c a l l y , medical manpower s u b s t i t u t i o n studies u s u a l l y i n v e s t i g a t e potential gains i n cost effectiveness by f i r s t examining the s k i l l s and practice p r i v i l e g e s required to deliver the procedures b i l l e d under p a r t i c u l a r t a r i f f items and then calculating potential savings for those t a r i f f items which offer the p o s s i b i l i t y of substitution. In these studies, because there i s a one-to-one correspondence between t a r i f f items and s p e c i f i c procedures, the e f f e c t s on s u b s t i t u t i o n p o s s i b i l i t i e s of treatment s u b s t i t u t a b i l i t y and p r a c t i c e p r i v i l e g e c o n s t r a i n t s can be evaluated with an examination of t a r i f f items alone. However, i n the case of private practice psychiatry services, t a r i f f items are commonly designated as classes of service (e.g., o f f i c e v i s i t ) rather than as s p e c i f i c procedures. Hence, although the e v a l u a t i o n of the e f f e c t s of p r a c t i c e p r i v i l e g e constraints can proceed, as usual, from an examination of t a r i f f items, the evaluation of treatment s u b s t i t u t a b i l i t y must proceed from an examination of the treatment practices associated with p a r t i c u l a r diagnostic codes; then the effects of the two variables can be examined i n combination to determine the substitutable share of services and costs. While we are p r i n c i p a l l y concerned i n the present research project with substitution p o s s i b i l i t i e s f o r p r i v a t e p r a c t i c e p s y c h i a t r y i n B r i t i s h Columbia, since the disaggregated B r i t i s h Columbia Medical Services Commission (BCMSC) data on expenditures for these services do not include diagnostic code, i t has been necessary for methodological reasons to use data from the Manitoba Health Services Commission (MHSC), which do in c l u d e diagnostic code. Thus, i n the i n i t i a l stages of the analysis I have used the 1 36 Manitoba data to estimate the substitutable share of services and costs as determined by the f i r s t two co n t r o l l i n g variables, treatment s u b s t i t u t a b i l i t y and practice p r i v i l e g e constraints. I have then related the estimates of the substitutable share of costs derived from the MHSC data to the BCMSC data to project the cost implications of manpower substitution for B r i t i s h Columbia p r i v a t e p r a c t i c e p s y c h i a t r y services, introducing the t h i r d c o n t r o l l i n g variable, r e l a t i v e payment rate. An analysis was made of MHSC data for f i s c a l years 1982, 1983, and 1984, containing the b i l l i n g s by a l l medical practitioners for the treatment of mental disorders, i n order to determine the consistency across years of the d i s t r i b u t i o n of b i l l i n g s across diagnostic codes. Data for th i s validation stage were f o r a l l medical p r a c t i t i o n e r s rather than s p e c i f i c a l l y for ps y c h i a t r i s t s , because the former data were available at no cost to the i n v e s t i g a t o r whereas the l a t t e r data were not. The data were i n the following disaggregated format: Diagnostic Code x Number of Patients x Number of Services x Amount Paid Within each year, the percentage which each diagnostic code accounted for of the t o t a l number of patients, number of s e r v i c e s , and amount paid was c a l c u l a t e d . Then a Pearson product moment correlation c o e f f i c i e n t was calculated for each possible f i s c a l year combination. As the percentages within each diagnostic category were quite consistent across the three f i s c a l years sampled (r = .98 to .99), i t was decided that data from a single year could be considered representative of the general pattern of b i l l i n g s for the treatment of mental disorders. Then the MHSC data for f i s c a l year 1984 for the b i l l i n g s by psychiatrists i n private practice were obtained (see Appendix C). These data were i n the same disaggregated format as the data for a l l 1 37 medical practitioners but with the addition of the s p e c i f i c t a r i f f items b i l l e d within each diagnostic code: Diagnostic Code x T a r i f f Item x Number of Patients x Number of Services x Amount Paid I t was these data that were used i n the present study to derive quantitative estimates of substitutable services and costs for private practice psychiatry services. Data were also obtained from the BCMSC on the t o t a l expenditures for private practice psychiatry services for f i s c a l year 1984 (see Tables XIX and XXII) and i t was these data that were used to p r o j e c t the cost implications of manpower substitution for B r i t i s h Columbia. 8.1 ESTIMATING SUBSTITUTABLE SHARE OF SERVICES AND COSTS The substitutable share of services and costs for private practice p s y c h i a t r y services i s considered to be a function of the combined effect of two variables, treatment s u b s t i t u t a b i l i t y (TS) and practice p r i v i l e g e constraints (PPC). As noted i n Chapter 2, i n the present study, q u a n t i f i c a t i o n of overlapping s k i l l s was accomplished by assigning numerical values to the p o s s i b i l i t y of treatment substitution (TS%) for each of the diagnostic codes i n the ICD-9-CM c l a s s i f i c a t i o n system for mental disorders. Likewise, quantification of overlapping services was accomplished by assigning numerical values to the degree to which psychologists would be permitted to deliver services (PPC%) for each t a r i f f item b i l l e d by psychiatrists to the MHSC for FY 1984. In order to generate s e v e r a l p o s s i b l e s u b s t i t u t i o n s c e n a r i o s , two conditions were defined for each of the two variables. Numerical values were assigned to TS under two conditions, a \"conservative\" condition and an \"extended\" condition, and to PPC under two conditions, an \"existing\" condition and a \"potential\" condition. F i r s t , estimates of the effects 1 38 of TS arid PPC on the p o s s i b i l i t i e s for manpower substitution were investigated separately and their r e l a t i v e importance evaluated. That i s , the effects of TS on the potential for manpower substitution were calculated under the \"conservative\" c o n d i t i o n and the \"extended\" c o n d i t i o n and, l i k e w i s e , the e f f e c t s of PPC on the potential for manpower substitution were calculated under the \"existing\" condition and the \"potential\" condition. Next, the combined effect of TS and PPC was calculated to determine the substitutable share of services and costs for a l l the private practice psychiatry services b i l l e d to the MHSC i n FY 1984. The sub s t i t u t a b l e share of a l l s e r v i c e s and costs was calculated for each of the four possible scenarios generated by the conditions defined for TS and PPC.(See Figure IX): Base Case: Conservative TS x Existing PPC Intermediate Case 1: Conservative TS x Potential PPC Intermediate Case 2: Extended TS x Existing PPC Best Case: Extended TS x Potential PPC F i n a l l y , the substitutable share of services and costs was calculated for the subset of b i l l i n g s for psychotherapy services as considered separately from the larger set of b i l l i n g s . As w i l l be discussed i n greater d e t a i l below, because the value of PPC i s constant i n the case of psychotherapy services, only two possible scenarios are generated for psychotherapy services by the conditions defined for TS and PPC (see Table IX): Base Case\/Intermediate Case 1: Conservative TS x Existing\/Potential PPC Intermediate Case 2\/Best Case: Extended TS x Existing\/potential PPC This i n v e s t i g a t i o n of the subset of psychotherapy services was undertaken f o r two reasons. F i r s t , the d i s c u s s i o n of s i m p l e substitution p o s s i b i l i t i e s i n the preceding chapters has focussed 1 39 TABLE IX Four Scenarios for Estimating Substitutable Share and Projecting Cost Implications of Manpower Substitution ALL SERVICES AND COSTS Treatment S u b s t i t u t a b i l i t y Conservative Extended Practice P r i v i l e g e Constraints Base Case Intermediate Case 2 E x i s t i n g Conservative TS X E x i s t i n g PPC Extended TS x Exi s t i n g PPC Intermediate Case 1 Best Case P o t e n t i a l Conservative TS X P o t e n t i a l PPC Extended TS X P o t e n t i a l PPC PSYCHOTHERAPY SERVICES AND COSTS Treatment S u b s t i t u t a b i l i t y Conservative Extended Base Case\/ Intermediate Case 2\/ Intermediate Case 1 Best Case Conservative TS Extended TS X X E x i s t i n g \/ P o t e n t i a l PPC Exi s t i n g \/ P o t e n t i a l PPC 140 p r i n c i p a l l y on psychotherapy s k i l l s and s e r v i c e s as an area of considerable overlap i n the train i n g and licensing of the four core mental health professions. Therefore, i t appeared to be important to determine the proportion that psychotherapy services accounted for of t o t a l p r i v a t e p r a c t i c e psychiatry services and costs and the cost implications of manpower s u b s t i t u t i o n f o r psychotherapy s e r v i c e s . Second, i n developing a general model for projecting potential economies from manpower substitution i n mental h e a l t h s e r v i c e d e l i v e r y , the examination of the subset of psychotherapy services appeared to offer a useful opportunity to demonstrate the c a p a b i l i t i e s of the model f o r generating cost implications from a number of di f f e r e n t perspectives, including i s o l a t i n g the cost implications of manpower substitution for a subset of services within the larger service pattern. In a s s i g n i n g numerical v a l u e s to TS, TS was r e p r e s e n t e d q u a n t i t a t i v e l y by an estimate of the p o s s i b i l i t y f o r treatment substitution (TS%) for each of the diagnostic codes i n the ICD-9-CM c l a s s i f i c a t i o n system. These estimates were, i n turn, based on the \"low,\" \"moderate,\" and \" h i g h \" l e v e l s of simple s u b s t i t u t i o n p o s s i b i l i t i e s developed i n Chapter Seven (see Tables VIII & X). In the \"conservative\" c o n d i t i o n , as i n the designation of the s i m p l e substitution levels themselves, I have endeavored to err on the side of caution. For services b i l l e d within diagnostic codes i n the \"low\" substitution category, that i s , for the treatment of disorders which are t y p i c a l l y treated i n the pharmacotherapy treatment mode and\/or the therapy team management mode, I have chosen to consider the treatment of these disorders i n private practice psychiatry as non- s u b s t i t u t a b l e without further study; hence, the percentage of substitutable services for these diagnostic codes was estimated to be zero percent (Diagnostic 1 41 Codes: 290-299, V63-V71). For services b i l l e d to diagnostic codes i n the \"moderate\" s u b s t i t u t i o n category, which the therapy outcome l i t e r a t u r e i n d i c a t e s can be tr e a t e d e f f e c t i v e l y i n e i t h e r the psychotherapy or the pharmacotherapy treatment modes and i n the single t h e r a p i s t management mode i n a considerable p r o p o r t i o n of thei r subclassifications and phases, the percentage of substitutable services was estimated to be 40 to 60 percent (Diagnostic Codes: 300, 303-308, 310, 311, 313, 314, 316-319). For services b i l l e d to diagnostic codes i n the \"high\" s u b s t i t u t i o n category, which the therapy outcome l i t e r a t u r e indicates can be treated e f f e c t i v e l y i n the psychotherapy treatment mode and the single therapist management mode, the percentage of s u b s t i t u t a b l e s e r v i c e s was estimated to be 60 to 80 percent (Diagnostic Codes: 301, 302, 309, 312, 315, V61, V62). In making the \"extended\" estimates, I have taken the view that since the therapy outcome l i t e r a t u r e on the treatment of disorders i n the \"moderate\" and \"high\" substitution categories has repeatedly demonstrated psychotherapy alone to be equally or more e f f e c t i v e than pharmacotherapy alone or psychotherapy and pharmacotherapy combined, policy makers might wish to consider the p o s s i b i l i t y of encouraging treatment using psychotherapy and so the \"extended\" treatment s u b s t i t u t a b i l i t y estimate was made to f a c i l i t a t e such a consideration. In the \"extended\" condition, for services b i l l e d i n the \"low\" category, the percentage of substitutable services was s t i l l estimated to be zero percent; however, for services b i l l e d to diagnostic codes i n the \"moderate\" category, the estimate of the percentage of substitutable services was increased to 60 to 80 percent, and for services b i l l e d to diagnostic codes i n the \"high\" category, the percentage of substitutable services was increased to 80 to 100 percent. 142 TABLE X Estimates of Treatment S u b s t i t u t a b i l i t y ESTIMATED PERCENTAGE OF GROUP DIAGNOSTIC CODE (ICD-9-CM) TREATMENT SUBSTITUTABILITY Conservative E x t e n d e d Condition Condition Low 290 Senile & Presenile Organic Psychoses 0% 0% 291 Alcoholic Psychoses 292 Drug Psychosis 293 Transient Psychoses 294 Other Organic Psychoses 295 Schizophrenic Psychoses 296 Affective Psychoses 297 Paranoid States 298 Other Nonorganic Psychoses 299 Psychoses with Origin Specific to Childhood V63 No Medical F a c i l i t y for Care V64 Procedures Not Done V65 Other Reasons for Consultation V66 Convalescence V67 Follow-up V68 Administrative Encounter V70 General Medical Examination V71 Observation of Suspected Condition Moder-ate 300 Neurotic Disorders 40-60% 60-80% 303 Alcohol Dependence 304 Drug Dependence 305 Nondependent Drug Abuse 306 Somatoform Disorders 307 Special Symptoms NEC1 308 Acute Reaction to Stress 310 Nonpsychotic Brain Disorders 311 Depressive Disorder NEC 313 Emotional Disturbance of Childhood\/Adolescence 314 Hyperkinetic Syndrome of Childhood 316 Psychosomatic Disorders 317 Mild Mental Retardation 318 Other Specified Mental Retardation 319 Unspecified Mental Retardation High 301 Personality Disorders 60-80% 80-100% 302 Sexual Deviations and Disorders 309 Adjustment Reaction 312 Conduct Disorder NEC 315 Specific Delays i n Development V61 Other Family Circumstances V62 Other Psychosocial Circumstances NEC: Not Elsewhere C l a s s i f i e d 1 43 In a s s i g n i n g numerical values to PPC, PPC was represented quantitatively by an estimate of the degree to which psychologists would be permitted to deliver services (PPC%) for each t a r i f f item b i l l e d to the MHSC by psychi a t r i s t s i n FY 1984. In assessing the effects of pr a c t i c e p r i v i l e g e constraints on substitution p o s s i b i l i t i e s , i t was necessary to consider the constraints placed on p s y c h o l o g i s t s with regard to c l i n i c a l hospital p r i v i l e g e s and the performance of medical procedures. In the \"existing\" condition, i t was decided to consider services delivered i n hospital as completely r e s t r i c t e d ; psychologists i n Canada have not yet been granted independent hospital admitting and discharge p r i v i l e g e s and such pr i v i l e g e s could be considered essential i n t h e i r substitution for private practice p s y c h i a t r i s t s . However, i n the \"potential\" condition, since psychologists i n the United States do have independent hospital privileges i n a number of j u r i s d i c t i o n s , services delivered i n hospital were considered as not r e s t r i c t e d . In the case of medical procedures, since psychologists are neither trained nor licensed to deliver these services, services b i l l e d to these t a r i f f items were considered as completely r e s t r i c t e d under both the \"existing\" and the \"potential\" conditions. The MHSC data i n d i c a t e that psychiatrists i n private practice submitted b i l l i n g s under 28 t a r i f f items i n FY 1984. For the purposes of investigating the effe c t of practice p r i v i l e g e constraints on the potential for manpower substitution, t a r i f f items were placed i n f i v e groups (see Table XI). Group I includes those t a r i f f items which are delivered only i n the o f f i c e or home (Tariff Items: 8507, 8550, 8553, 8554, 8580, 8581, 8583, 8589); for Group I, the percentage of services judged permitted by practice p r i v i l e g e constraints was estimated to be 100 percent under both the \"existing\" and the \"potential\" conditions. 144 Group I I includes t a r i f f items delivered i n the o f f i c e , home, or hospital ( T a r i f f Items: 8503, 8504); for Group I I , the percentage of services judged permitted by constraints was estimated to be 66 percent i n the \" e x i s t i n g \" c o n d i t i o n and 100 percent i n the \" p o t e n t i a l \" condition. Group I I I includes t a r i f f items delivered i n the home or hospital (Tariff Items: 8561, 8563); for Group I I I , the percentage of s e r v i c e s judged not affected by constraints was estimated to be 15 percent i n the \"existing\" and 100 percent i n the \"potential\" condition. Group IV includes t a r i f f items which are delivered only i n hospital (Tariff Items; 8511, 8519, 8522, 8525, 8528, 8531, 8532, 8534, 8572, 8573, 8574); for Group IV, the percentage of services judged permitted by constraints was estimated to be zero percent i n the \" e x i s t i n g \" c o n d i t i o n and 100 percent i n the \"po t e n t i a l \" condition. Group V includes t a r i f f items which are medical procedures (Tariff Items: 8509, 8540, 8588, 8954, 8957); for Group V, the percentage of services judged permitted by constraints was estimated to be zero percent under both the \"existing\" and the \"potential\" conditions. Thus, i n summary, i n the \"existing\"'condition, psychologists are assumed to be unable to provide e i t h e r services delivered i n hospital or services which are medical procedures; hence for the \"existi n g \" c o n d i t i o n , the e n t i r e set of r e s t r i c t i o n s on practice p r i v i l e g e s l i s t e d above i s included, that i s , the r e s t r i c t i o n s which apply to the t a r i f f items i n Groups II-V. However, under the \"potential\" condition, psychologists are assumed to be able to provide services d e l i v e r e d i n h o s p i t a l and hence t h i s condition includes only the r e s t r i c t i o n s which apply to the performance of medical procedures, that i s , to the t a r i f f items i n Group V. TABLE XX Estimates or Practice Privilege Constraints GUUUV TARIFF i TJEH (M33C: Ipdl 1, 1985) UXaXUH OF raiTHxrar) HKOHUGK l-l OS x w < co OS o u, 00 00 o o u. o 00 H \/-> Z co M e < W \u2022J X M >